Psychiatric disorders are more commonly seen in the general medical outpatient and inpatient settings than in community samples. This group is at particular risk for resistance to general medical and psychiatric treatment, increased complications of disease, high use of health care services, and disability. Several randomized, controlled studies have shown that integrated medical and psychiatric treatment is clinically and economically effective. For this reason, "integrated" physical and mental-health primary care models and inpatient models should receive greater attention as we attempt to improve the quality of care and health outcomes for patients with comorbid medical and psychiatric disorders. Because there are too few consultating psychiatrists to deliver services to the many medically ill patients with psychiatric disorders, we should consider new efficient and effective proactive approaches in the future rather than relying on the current reactive psychiatric consultation system. For cost-effective treatment in these budget- and manpower-limited environments, a multidisciplinary team approach, which coordinates psychiatric service delivery under specially trained psychiatrists, should be used. Specially trained psychiatrists should be multidisciplinary team leaders who support and encourage interventions by other behavioral health specialists with selected skills.
Introduction: Laparoscopic assisted colectomy (LAC) for early colorectal cancer has been established and been proven to be equivalent to open colectomy in terms of survival and safety. Although the indications for LAC in advanced colorectal cancer remain controversial, LAC has been performed increasingly often. Purpose: To clarify the selection criteria of laparoscopic surgery for advanced colorectal cancer. Methods: The indications for laparoscopic surgery in advanced colorectal cancer were established from 2001∼2004, as: 1) the cecum, ascending colon, descending colon, sigmoid colon, and rectosigmoid colon, 2) tumor depth within the subserosa, 3) no regional lymph node involvement, and 4) no distant metastasis. Indications established from 2005 to 2007 were: 1) all colorectal cancer with none in the lower rectum, 2) no distant metastasis, and 3) no direct invasion to neighboring organs. The reasons to exclude indications and the exclusion factors for laparoscopic colectomy for advanced colorectal cancer were analyzed. Results: The percentage of cases consistent with the indications were 55% (2001∼2004) and 78% (2005∼2007). The reasons for exclusion were liver metastasis (19% and 40%), tumor location (33% and 37%), direct invasion to the neighboring organs (21% and 17%), and peritoneal dissemination (3% and 6%). The exclusion factors for laparoscopic colectomy were tumor size (31% and 27%), synchronous malignancies (11% and 26%), ileus and emergencies (17% and 14%), history of previous abdominal surgery (15% and 14%), age and general condition (17% and 9%), and obesity (8% and 5%). There was no significant difference between the short-term performance of LAC from 2001∼2004 and from 2005 to 2007. Operation time, blood loss, conversion rate to open surgery and postoperative complications were similar between the patients with a body mass index (BMI) less than 25 and those with a body mass index greater than 25. Conclusion: Practical indications for LAC in advanced colorectal cancer are 1) all colorectal cancer with none in the lower rectum, 2) no distant metastasis, and 3) no direct invasion to neighbouring organs. Obesity is not necessarily an exclusion factor for LAC. However long-term analysis is still necessary.
Despite strict adherence to standard precautionary methods, such as hand washing, isolation precaution, and individual use of various devices, methicillin-resistant Staphylococcus aureus (MRSA) has become epidemic in our neonatal intensive care unit (NICU). To prevent nosocomial MRSA transmission via the hands of hospital personnel, we have worn gloves while caring for neonates since July 2005. The colonization rate of MRSA was calculated as the ratio of the neonates colonized with MRSA to the total number of neonates in our NICU. With the glove precaution, the mean colonization rate has decreased from 20% (April 2004 through June 2005) to 8.8% (July 2005 through June 2006). This study suggests that the glove precaution can significantly reduce the nosocomial transmission of MRSA, although it might be necessary to survey MRSA carriers and search for effective control measures in each NICU.
Pelvic organ prolapse (POP) is characterized by a lack of pelvic floor support, which causes the pelvic organs and vaginal wall to protrude. For many decades, suture repair techniques have been the primary choice of surgical treatment when indicated. Traditional surgical techniques are, however, associated with a high recurrence rate. Since 1996, vaginal mesh surgery for treatment of POP has been performed with several types of procedure. Among these procedures, the tension-free vaginal mesh (TVM) procedure is expected to be effective for reconstruction of the pelvic floor and to be applicable to almost all types of POP. Gynemesh (Gynecare Ethicon, Somerville, NJ, USA), a thin, high-porosity synthetic polypropylene prosthesis, is inserted as a hammock under the bladder, applied laterally on the arcus tendineus fasciae pelvis, and retained by two unsecured bilateral transobturator arms. A posterior interrectovaginal prosthesis is inserted in front of the rectum and applied laterally on the levatores ani, retained by a bilateral lateral arm secured to the median part of the sacrospinous ligament. We used TVM to treat 40 cases of POP from May 1, 2007, to June 30, 2008. We have applied both anterior and posterior meshes in 29 cases and an isolated anterior mesh only in 10 cases. The TVM was quite effective for all types of POP, including recurrent cases. However, bladder injury (3 cases) and rectal injury (1 case) occurred during this period. We believe that TVM is a decisive innovation in the treatment of POP, but surgeons must be familiar with its technical details before practice.
To evaluate the efficacy and safety of chemoradiation therapy with docetaxel, fluorouracil, and nedaplatin for the patients with esophageal cancer and simultaneous double primary malignancy. Three patients with inoperable disease were enrolled to receive the combination of docetaxel 40mg/m2 (on days 1 and 21), nedaplatin 10mg/body (on days 1∼5 and 21∼25), and fluorouracil 350mg/m2 (on days 1∼5 and 21∼25) with radiation (60Gy in 2-Gy fractions over 6 weeks). Evaluated responses were a complete response in 1 patient and partial responses in 2 pateints. The overall response rate was 100%. Myelosuppressions with grade 2 leukopenia occurred in 2 patients (66%). This chemoradiation therapy is effective for and well-tolerable by patients with esophageal cancer and simultaneous double primary malignancy.
Recently, complementary (c) DNA full-length clone transfection and gene silencing with the small interfering (si) RNA method have emerged as new methods for elucidating intracellular signaling pathways in cultured cell lines. However, these methods have rarely been used in the field of neuroendocrinology. Recent reports have shown the presence of a novel matrix metalloproteinase (MMP)-inhibiting cell membrane-anchored glycoprotein designated "reversion-inducing cysteine-rich protein with Kazal motifs" (RECK). The purpose of this study was to elucidate the role of RECK in the cell invasion of pituitary adenomas and its contribution to signal transduction. The function of RECK in cell invasion was investigated by comparing data obtained from full-length RECK clone transfection and gene silencing with RECK messenger RNA-targeting siRNA. RECK expression was confirmed by means of real-time reverse transcription polymerase chain reaction and Western blotting. Levels of MMP-2 and MMP-9 and of tissue inhibitor of metalloproteinases-1 were measured with zymography and reverse zymography, respectively. Cell invasion was examined with a 3-dimensional invasion assay. The signal cascade was investigated with cDNA microarray analysis. As expected, expression of RECK was elevated upon cDNA transfection and decreased with siRNA. We observed elevations of MMP-2 and MMP-9 expression and consequent 3-dimensional cell invasion in cells under-expressing RECK. However, expression of tissue inhibitor of metalloproteinases was not affected by RECK. cDNA microarray analysis revealed that RECK additionally up-regulates growth hormone-releasing hormone receptor and latrophilin 2 at the transcriptional level. Our findings collectively suggest that RECK regulates the cell-signalling pathway and plays a critical neuroendocrinological role in the pituitary adenoma cell line.
Drug-induced hypersensitivity syndrome (DIHS) is a rare but severe disease associated with multiorgan failure. The association of DIHS with human herpes virus 6 (HHV-6) has recently been reported. We report on an 89-year-old woman with allopurinol-induced DIHS diagnosed on the basis of symptoms and laboratory examinations. A rash appeared as erythema on the trunk and extremities and edematous erythema on the face. Renal dysfunction, leukocytosis, eosinophilia, and atypical lymphocytes were also present. An elevated titer of antibodies against HHV-6 and HHV-6 DNA in the blood were observed during the course of the disease (1 : 20 to 1 : 1280). Discontinuation of allopurinol administration and systemic corticosteroid treatment led to an improvement, but symptoms worsened when the corticosteroid dosage was tapered. An elevated titer of antibodies against cytomegalovirus was detected during the course of the disease. The patient died of pneumonia, most likely related to cytomegalovirus. This case indicates that, in addition to the reactivation of HHV-6, reactivation of cytomegalovirus may modify clinical disease activity.