Purpose: We evaluated the effectiveness of catheter-retaining balloon-occluded retrograde transvenous obliteration (BRTO). Patients and Methods: Patients were divided into 2 groups based on concurrent contrast imaging findings. The primary endpoint was effectiveness, the secondary endpoint was complications, and the tertiary endpoint was recurrence of esophageal varices in all cases. Results: The mean volume of EO administered was 16.43±4.37 overall and was significantly lower in group 1 (40.61±14.95 mL; 15 patients, 32.6%) than in group 2 (31 patients, 67.4%). The number of injections was 1.60±0.63 in group 1 and 2.97±0.60 in group 2, and the volume of EO used in 1 day did not differ significantly between group 1 (12.28±6.48 mL) and group 2 (13.54±3.12 mL). The disappearance rate of varices was significantly greater in group 1 (100%) than in group 2 (90.3%). Fever developed in 33.3% of patients in group 1 and 87.1% of patients in group 2. The rates of recurrence of esophageal varices 2, 4, and 9 years after the procedure were 34%, 48%, and 57%, respectively. Conclusion: These results show that catheter-retaining BRTO is a simple and highly effective procedure for difficult cases with minor complications. Furthermore, catheter-retaining BRTO does not require a large daily dose of EO and is, therefore, an effective treatment for solitary gastric varices.

View full abstract

Background and Purpose: Few studies have described the risk factors associated with the development of neurological pulmonary edema (NPE) after subarachnoid hemorrhage (SAH). We have hypothesized that acute-phase increases in serum lactate levels are associated with the early development of NPE following SAH. The aim of this study was to clarify the association between lactic acidosis and NPE in patients with nontraumatic SAH. Methods: We retrospectively evaluated 140 patients with nontraumatic SAH who were directly transported to the Nippon Medical School Hospital emergency room by the emergency medical services. We compared patients in whom NPE developed (NPE group) and those in whom it did not (non-NPE group). Results: The median (quartiles 1-3) arrival time at the hospital was 32 minutes (28-38 minutes) after the emergency call was received. Although the characteristics of the NPE and non-NPE groups, including mean arterial pressure (121.3 [109.0-144.5] and 124.6 [108.7-142.6] mm Hg, respectively; P=0.96), were similar, the median pH and the bicarbonate ion (HCO₃^-) concentrations were significantly lower in the NPE group than in the non-NPE group (pH, 7.33 [7.28-7.37] vs. 7.39 [7.35-7.43]); P=0.002; HCO₃^-, 20.8 [18.6-22.6] vs. 22.8 [20.9-24.7] mmol/L; P=0.01). The lactate concentration was significantly higher in the NPE group (54.0 [40.3-61.0] mg/dL) than in the non-NPE group (28.0 [17.0-37.5] mg/dL; P<0.001). Multivariable regression analysis indicated that younger age and higher glucose and lactate levels were significantly associated with the early onset of NPE in patients with SAH. Conclusion: The present findings indicate that an increased serum lactate level, occurring within 1 hour of the ictus, is an independent factor associated with the early onset of NPE. Multicenter prospective studies are required to confirm our results.

View full abstract

Purpose: Despite producing pain, angiolipoma is sometimes misdiagnosed as an ordinary small lipoma, which is usually not associated with pain. Few reports have described magnetic resonance (MR) imaging findings of angiolipoma. The aim of the present study was to clarify the MR imaging features of angiolipoma. Materials and Methods: The MR imaging findings of 11 lesions in 7 patients were reviewed and compared with histopathological findings. Results: The MR imaging features of these lesions were the presence of fat nodules with or without areas of low signal intensity on T1- and T2-weighted images. The location of the low-signal-intensity areas varied. The low-signal-intensity areas were mainly in the peripheral portion of 3 lesions and in the central portion of 5 lesions. No or few low-signal-intensity areas were observed in 3 lesions. In the lesions with peripheral low-signal-intensity areas, lesion marginations were well defined, and the lesions were easily recognized as mass lesions. In the lesions with only central low-signal-intensity areas, marginations were poorly defined, and the lesions were not easy to recognize as mass lesions. In the lesions with few or without low-signal-intensity areas, marginations were invisible. Histopathological studies indicated that the low-signal-intensity areas on T1- and T2-weighted images corresponded to areas of dense capillary proliferation. In lesions with few or without low-signal-intensity areas on MR images, capillaries were thinly spread over almost the entire lesion area. Conclusion: The MR imaging features of angiolipoma are fat nodules with or without low-signal-intensity areas of various size and location on T1- and T2-weighted images.

View full abstract

Introduction: The incidence of preventable trauma death in the current Japanese emergency medical system remains high. The present study aimed to determine rates of clearly preventable and possibly preventable trauma deaths due to traffic accidents in Chiba Prefecture, Japan, and to consider associated problems and solutions. Materials and Methods: During 2011, 175 victims died after traffic accidents in Chiba Prefecture. Of these, the deaths of 69 persons who had vital signs at the time of emergency medical service contact were classified as clearly preventable, possibly preventable, or not preventable through the peer review discussion. We also examined problems associated with deaths that were clearly preventable or possibly preventable. Results: Of the 69 deaths, 9 (13%) were classified as clearly preventable, 11 (16%) as possibly preventable, and 49 (71%) as not preventable. Of the 20 clearly or possibly preventable deaths (each death potentially comprising multiple problems), 5 were related to selection of the hospital before hospital arrival, 4 to problems with regional emergency medical systems, and 15 to inappropriate hemodynamic management, including transfusion and delayed (or not attempted) hemostasis in the hospital. Discussion: Problems of these 20 deaths showed that appropriate triage at the scene, centralization of patients with severe trauma, and trauma centers are necessary in Japan. Under-triage before arrival at the hospital was related to clearly and possibly preventable deaths. Upgrading the triage category for victims with torso injury must be considered. Not all emergency critical care centers in Japan are able to provide severe trauma care. Preventable trauma deaths occur even in some emergency critical care centers; therefore, we need centralization of severe trauma patients from wider area to reduce the incidence of preventable trauma death.

View full abstract

Objective: The aim of this study was to examine the effects of a newly established neonatal intensive care unit (NICU) on clinical work practice and educational activity at Nippon Medical School Musashikosugi Hospital. Methods: This retrospective study analyzed the clinical records of all neonates admitted to the NICU from December 2010 through November 2013. Anthropometric data, clinical status, problems, and outcomes of patients and the related obstetrical history were extracted and analyzed. Results: Of the 568 neonatal admissions, about half were related to preterm birth (49%) and low birth weight (55%). Forty-eight percent of patients were born via caesarean delivery. Maternal hypertension, diabetes, and thyroid disease were found in 8%, 5%, and 2% of cases, respectively. Mechanical ventilatory support was provided for 20% of patients. Neonates from multiple pregnancy and with significant congenital anomalies accounted for 17% and 10% of all patients, respectively. Five patients died during hospitalization. In addition training was provided in the NICU for an average of 10 residents and 20 medical students per year. Conclusion: Since the NICU was established, closer cooperation beyond the framework of a single department has come to be needed. In addition, NICUs in teaching hospitals are expected to provide opportunities for medical students and residents to observe and participate in multidisciplinary medical care.

View full abstract

We describe a 39-year-old woman with metastatic breast cancer who had grade 4 epistaxis induced by bevacizumab. The patient visited our outpatient clinic with complaints of a lump in her right breast, fatigue, dyspnea, abdominal distention, appetite loss, and weight loss of 10 kg over 1 year. Liver dysfunction was detected, with elevated levels of aspartate aminotransferase (271 IU/L), alanine aminotransferase (100 IU/L), alkaline phosphatase (4,205 IU/L), total bilirubin (2.7 mg/dL), and direct bilirubin (2.1 mg/dL). A secondary liver tumor that occupied most of the liver volume was found, and bone metastasis, ascites, and pleural effusion were also discovered. The Eastern Cooperative Oncology Group performance status was 2. A core needle biopsy of the right breast tumor revealed invasive ductal carcinoma of the breast (nuclear grade 1) that was positive for estrogen receptor and progesterone receptor and negative for human epidermal growth factor receptor 2 overexpression and had a high Ki-67 score. We chose combination chemotherapy with paclitaxel (80 mg/m² on days 1, 8, and 15) and bevacizumab (10 mg/kg on days 1 and 15) for 28 days (1 cycle). After completion of the first cycle of chemotherapy, the ascites and pleural effusion decreased, and the metastatic liver tumor shrank. The performance status improved from 2 to 1. On day 3 of the third cycle of chemotherapy, however, she began having persistent epistaxis. On day 6, she lost consciousness and was transported to the emergency room of our hospital. The hemoglobin level was 5.6 g/dL. Blood transfusion and endoscopic hemostasis were immediately started. Bevacizumab was discontinued, and paclitaxel alone was continued; after this change, epistaxis did not recur.

View full abstract

We report on a 14-year-old girl with hydrocephalus that underwent spontaneous regression without any specific treatment, such as ventriculoperitoneal shunt surgery. A 14-year-old girl was referred to our hospital with severe headache, dizziness, nausea, and vomiting. Computed tomography and FLAIR-MRI findings on admission showed markedly dilated lateral, third and fourth ventricles with periventricular hyperintensity and downward displacement of the tonsils induced by dilatation of the fourth ventricle. We diagnosed hydrocephalus of unknown etiology. Although no specific treatment for hydrocephalus was performed, the symptoms gradually improved. One year after onset, the patient was completely free of neurological symptoms, and findings of physical examination and magnetic resonance imaging of the brain had returned to normal. The etiology of the spontaneous regression is unclear, but the following mechanisms are discussed: 1) rupture of ventricular diverticulum, 2) head injury causing skull-base fracture with leakage of cerebrospinal fluid, 3) extremely radiosensitive neoplasms diminished by X-p exploration, and 4) cerebrospinal fluid leakage due to lumbar puncture.

View full abstract

Patients with acute type B aortic dissection (ABAD) are often treated medically. However, ABAD is a potentially serious emergency if complicated by acute organ ischemia. The therapeutic strategy for ABAD with visceral malperfusion remains controversial. Because emergent surgery has a high mortality rate, emergent endovascular treatment can be performed instead. We report a case of endovascular fenestration with stenting for visceral malperfusion in ABAD. One stent was inserted across the intimal flap to keep the fenestrated site open, and another stent was placed into the narrowed true lumen. This therapeutic strategy may be feasible for ABAD with acute malperfusion.

View full abstract

The patient, a 56-year-old woman, was found during routine checkup to have a disorder of hepatic function. Abdominal ultrasonography showed an ill-defined hypoechoic mass in the head and body of the pancreas; however, no blood-flow signal was observed within the tumor on Doppler ultrasonography. Abdominal computed tomography showed a low-density area in the arterial and portal venous phases. The lesion was visualized as an area of low signal intensity on both T1- and T2-weighted magnetic resonance images, whereas fluorodeoxyglucose positron emission tomography showed fluorodeoxyglucose accumulation in the tumor. Although a preoperative diagnosis was difficult to make, a rapid cytologic examination revealed evidence of a pancreatic endocrine tumor, and subtotal stomach-preserving pancreaticoduodenectomy with portal vein resection was performed. Histopathological examination showed tumor cell nests scattered in abundant fibrotic tissue; the tumor cells had proliferated in a cord-like fashion and showed immunostaining for chromogranin A. Staining for fibroblast activation protein α was seen in the fibroblastic cells contained within the fibrous stroma surrounding the tumor cell nests, whereas both the fibroblastic cells in the tumor and those in the stroma showed a high rate of staining for thrombospondin. We presume that tumor-associated fibroblasts were involved in the fibrosis of the tumor stroma.

View full abstract