[Function of the Puborectalis Muscle in Patients with or without Fecal Incontinence Three Years after Low Anterior Resection for Lower Rectal Cancer]

To clarify the function of the puborectalis muscle(PM)in fecal incontinence(FI)prevention after low anterior resection (LAR)for lower rectal cancer(LRC), PM function at 3 years after LAR was studied. A total of 29 patients aged 40-79 years (19 men and 10 women, mean age: 63.9 years)who underwent LAR for LRC were enrolled in the present study. Based on the presence of postoperative FI, these patients were divided into 2 groups[group A: patients with FI(n=13), 11 men and 2 women aged 43-75 years(mean age: 64.8 years)and group B: patients without FI(continence, n=16), 8 men and 8 women aged 41-79 years(mean age: 62.9 years)]. These groups were compared with group C of control subjects[n=38; 28 men and 10 women aged 42-76 years(mean age: 64.5 years)]. Magnetic stimulation at the S2-4 sacral levels has been shown to activate the sacral motor nerve(SMN)root of the cauda equina. SMN latency(SMNL)was determined on the right, left, and posterior sides of the upper anal canal. FI after LAR was also evaluated using the Wexner score(WS), with a score of 8 or more being associated with FI according to our data. All patients had pathological Stage Ⅰ disease(19 patients: T1, N0, M0; 10 patients: T2, N0, M0). Group A had a larger proportion of men than group B(p<0.1). The distance of anastomosis from the anal verge(DAAV)was significantly shorter in group A(2.2±1.2 cm)than in group B(4.6 ±1.3 cm)(p<0.001). Regarding WS of group A, 23.1% patients had a score of 8-10(mean: 9.0), 53.8% of 11-15 (mean: 13.4), and 30.7% of 16-20(mean: 17.0). All patients in group A(WS: 8 or more)were incontinent. In contrast, all patients in groups B(WS: 0)and C(WS: 0)were continent. Patients with preoperative defecation ability(WS: 0)were also continent. As for SMNL on the right(9 o'clock), left(15 o'clock), and posterior(18 o'clock)sides of the PM located in the upper anal canal, conduction delay was significantly longer in group A(8.4±0.6 ms, 8.2±1.9 ms, and 8.3±0.9 ms, respectively)than in groups B(4.4±0.5 ms, 4.3±0.7 ms, and 4.4±0.9 ms, respectively)and C(4.1±0.5 ms, 4.0±0.5 ms, and 4.2±0.7 ms, respectively)(p<0.001, all). FI after LAR with a short DAAV, especially in men, may cause PM dysfunction due to operative damage of the SMN.

[Relationships Gastric Stasis in the Remnant Stomach and Interdigestive Migrating Motor Complex in Patients after Pylorus-Preserving Gastrectomy for Early Gastric Cancer]

The demerit of pylorus-preserving gastrectomy(PPG)is the postprandial abdominal fullness(PAF)with gastric stasis in the remnant stomach(GSRS). We investigated the relationship between clinical findings and GSRS, and between GSRS and interdigestive migrating motor complex(IMMC)in PPG patients. A total of 30 patients(17 men and 13 women, mean age of 62.3 years)after PPG for early gastric cancer(Billroth Ⅰ)were divided into 2 groups(group A; 18 patients with GSRS, group B; 12 patients without GSRS). The relationship between GSRS including clinical findings and IMMC was studied from 1.5 to 3 years after operation. A catheter equipped with a micro-tip force transducer was inserted transnassally into the remnant stomach and duodenum in a supine position, and the IMMC was studied. All patients were Stage ⅠA(mucosal cancer, no lymph node metastasis, no distant metastasis). The remnant stomach was 1/3 compared with stomach size before operation. The length of the antral cuff in group A(1.5±0.2 cm)was significantly shorter than group B(3.2±0.3 cm)(p =0.0004). Appetite was significantly recognized in group B compared with group A(p=0.0067). PAF was significantly recognized in group A compared with group B(p=0.0001). Reflux esophagitis was found in group A more than group B. Early dumping syndroms did not found significant differences in both groups. In endoscopic esophagogastric finding of the remnant stomch, gastritis with GSRS was significantly found in group A compared with group B(p=0.0001). The IMMC was significantly recognized in group B compared with group A(p<0.0001). The occurrence of the PAF due to the GSRS may be caused by abscens of the IMMC.

[Role of Pudendal Sensory Nerve in Patients with or without Fecal Incontinence after Low Anterior Resection for Lower Rectal Cancer]

To clarify the pudendal sensory nerve(PSN)play in preventing fecal incontinence(FI)after low anterior resection(LAR) for lower rectal cancer, the PSN function was studied at 6 months after LAR. A total of 36 patients aged 42.0 to 79.0 years (23 males and 13 females with a mean age of 62.0 years)who underwent LAR for laparoscopic radical cystectomy(LRC) were enrolled in the present study. Based on postoperative F1, these patients were divided into 2 groups[group A; patients with FI(n=12), group B; patients without FI(continence, n=24)]. These were compared with group C(n=32, control subjects, 18 males and 14 females aged 40.0 to 76.0 years with a mean age of 61.8 years). Anal mucosal electric sensitivity (AMES)threshold was measured [at the upper 1 cm oral side from dentate line(DL); a, DL; b, and lower zones 1 cm anal side from DL; c]. FI after LAR was also evaluated by the Wexner score(WS). All patients were pathological Stage Ⅰ(25 patients: T1, N0, M0; 11 patients: T2, N0, M0). Group A had a significantly larger proportion of males than group B(p< 0.05). The distance of anastomosis from anal verge(DAAV)in group A(2.4±1.8 cm)was significantly shorter than in group B(4.4±0.9 cm)(p<0.001). WS from 6 to 10 comprised 25.0% of group A, 11 to 15 comprised 50.0%, and 16 to 20 comprised 25.0%. All patients in group A(WS; 8 or more)were incontinent. In contrast, all patients in group B(WS; 0) and C(WS; 0)were continent. Patients in pre-operative defecation(WS; 0)were also continent. On the AMES(a, b, c), sensitivity of patients in group A(6.4±1.1, 5.1±0.5, 4.9±0.6 mA)was significantly higher than in groups B(2.6±0.5, 2.4 ±0.4, 2.5±0.6 mA)and C(2.3±0.4, 2.1±0.4, 2.3±0.5 mA)at all zones(p<0.001). FI after LAR with a short DAAV, especially male, may be PSN dysfunction due to operative damage of PSN.

Supernormal Antithrombin Activity Is an Independent Predictor of In-Hospital Mortality in Patients With Sepsis: A Retrospective Observational Study

Supernormal antithrombin (AT) activity is rare in patients with sepsis. This study compared mortality rate of patients with sepsis and supernormal AT activity with that of other patients. This retrospective study included patients with sepsis from 42 intensive care units (ICUs) in Japan. Patients were included if their AT activity was measured on ICU admission, and if they did not receive AT concentrate. They were categorized into low, normal, and supernormal with respective AT activity of ≤70%, >70% to ≤100%, and >100%. The primary outcome was hospital in-patient mortality. Nonlinear regression analysis showed that mortality risk gradually increased with AT activity in the supernormal range, but without statistical significance. Survival rate was significantly lower in low (67%) and supernormal (57%) AT groups than in the normal AT group (79%; P < .001 and P = .008, respectively). After adjusting for disease severity and AT activity on day 2, supernormal AT activity was the only independent predictor of mortality. Sepsis with supernormal AT activity associated with high mortality, independent of disease severity, might be a predictor of in-hospital mortality.

[Function of Pudendal Motor Nerve in Patients with or Without Fecal Incontinence after Low Anterior Resection for Lower Rectal Cancer]

To clarify the pudendal motor nerve(PMN)play in preventing fecal incontinence(FI)after low anterior resection(LAR) for lower rectal cancer, the PMN function was studied at early postoperative period after LAR. A total of 30 patients aged 43 to 78 years (21 men and 9 women with a mean age of 62.4 years) who underwent LAR for LRC were enrolled in the present study. Based on postoperative FI, these patients were divided into 2 groups(group A: patients with FI[n=10], group B: patients without FI[continence, n=20]). These were compared with group C(n=28, control subjects, 18 men and 10 women aged 46 to 76 years with a mean age of 60.2 years). Magnetic stimulation at the S2-4 sacral levels has been shown to activate the PMN root of the cauda equina. PMN latency(PMNL)at posterior sides of the anal canal was studied. FI after LAR was also evaluated by the Wexner score(WS). All patients were pathological Stage Ⅰ(20 patients: T1, N0, M0; 10 patients: T2, N0, M0). Group A had a significantly larger proportion of men than group B(p<0.05). The distance of anastomosis from anal verge(DAAV)in group A(2.4±1.7 cm)was significantly shorter than in group B(4.4±0.9 cm)(p< 0.001). WS from 8 to 10(mean: 9.25)comprised 20.0% of group A, 11 to 15(mean: 13.5)50.0%, and 16 to 20(mean: 18.5)comprised 30.0%. All patients in group A(WS: 8 or more)were incontinent. In contrast, all patients in group B(WS: 0)and C(WS: 0)were continent. Patients in pre-operative defecation(WS: 0)were also continent. As for PMNL, the conduction delay in group A(7.9±0.9 ms)was significantly longer than in groups B(4.1±0.6 ms)and C(3.9±0.3 ms) (p<0.001, respectively). FI after LAR with a short DAAV may be EAS dysfunction due to damage of PMN.

[Primary Undifferentiated Pleomorphic Sarcoma of the Ileum-A Case Report]

Undifferentiated pleomorphic sarcoma(UPS)of the small intestine is extremely rare and has a poor prognosis. We encountered a case of primary UPS of the ileum without metastatic lesions. The patient was a 44-year-old man who presented with the chief complaint of lower abdominal pain for 9 months. He also presented with anemia, hypoproteinemia, and a lower abdominal tumor about 10 cm in size. Abdominal CT with cystography showed an irregular solid tumor with compression of the cystic bladder. Based on a presumptive diagnosis of the retroperitoneal tumor, he underwent laparotomy. An irregular tumor, 9×8×5 cm in size, was observed in the ileum approximately 60 cm from the terminal ileum. There were no lymph node, peritoneal, or liver metastases. Partial excision of 30 cm of the ileum from 50 cm to 80 cm at the terminal ileum was performed. The final histological diagnosis was primary UPS(storiform pattern with fibroblast-like spindle cells). The patient was not administered adjuvant chemotherapy and was discharged on postoperative day 10. He is currently well without any evidence of recurrence for 2 years after the surgery.

[Postprandial Abdominal Fullness after Pylorus-Preserving Gastrectomy for Early Gastric Cancer]

To clarify the basis for postprandial abdominal fullness(PAF)in patients after pylorus-preserving gastrectomy(PPG), the authors investigated the relationship of PAF with postgastrectomy disorder(PGD)and gastric emptying function(GEF)in PPG patients. A total of 22 patients(14 men and 8 women, average age 64.8 years)were divided into 2 groups[Group A, PAF-positive(n=12); Group B, PAF-negative(n=10)]at 1 year after PPG for early gastric cancer. The relationships of PAF with PGD and GEF were examined. Length of the antral cuff(LAC)was significantly shorter in group A than in group B(p< 0.05). Appetite and food consumption per meal were significantly greater in group B than in group A(p<0.05 and p<0.01, respectively). Symptomatic reflux esophagitis(RE), early dumping syndrome, decreased percent body weight before illness, endoscopic RE, and endoscopic gastritis in the remnant stomach were more common in group A than in group B. Gastric stasis in the remnant stomach was significantly more common in group A than in group B(p=0.0071). GEF for solid food [time to 50%residual rate in the remnant stomach(minutes)and residual rate at 120 minutes in the remnant stomach(%)] in group A was significantly delayed compared with that in group B(p<0.001). Patients with PAF showed shorter LAC, delayed GEF for solid food, and worse postoperative quality of life(QOL), compared with those without PAF.

[A Case of Local Recurrence of Descending Colon Cancer with Ileus Obstruction and Lung, Liver and Brain Metastasis]

We report a 50-year-old man with local recurrence of descending colon cancer with ileus obstruction and brain metastasis, 2 years 6 months after initial resection due to perforation of descending colon cancer(Hartmann procedure, D2 lymph node resection, Stage II, tub2). He complained of left upper abdominal pain and abdominal fullness. He also complained of paresis of the right upper extremity and of experiencing convulsions 1 month before admission. He was diagnosed with local recurrence of descending colon cancer, based on findings of contrast radiography and the presence of colonic fiber. We subsequently performed transanal decompression as a bridge to surgery and performed partial resection of the local recurrence in the anastomosis at the descending colon and ileum involved with the cancer 2 weeks after decompression. In addition, multiple lung and liver metastases, and solitary brain metastasis(2.5 cm in size located in the left side of the parietal region) were detected by cerebral plain computed tomography. However, he refused both chemotherapy after surgery, as well as further surgery and/or radiation therapy for the brain metastasis. He desired to return to his home as soon as possible. In order to improve his quality of life(QOL), in-home treatment involving the best supportive care(BSC)conservative therapiesincluding, anticonvulsant and anti-intracranial hypertension drugs-were administered to prevent brain metastasis symptoms, such as paresis of the right upper extremities and convulsions. He was discharged from our hospital 14 days after surgery. Regrettably, he died due to bronchial asthma 75 days after palliative surgery in his home.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

BACKGROUND AND PURPOSE

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc.This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine.

METHODS

Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members.

RESULTS

A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs.

CONCLUSIONS

Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

Background and Purpose

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English-language version of these guidelines was created based on the contents of the original Japanese-language version.

Methods

Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (>66.6%) majority vote of each of the 19 committee members.

Results

A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs.

Conclusions

Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

Low-dose immunoglobulin G is not associated with mortality in patients with sepsis and septic shock

Background

The administration of low-dose intravenous immunoglobulin G (IVIgG) (5 g/day for 3 days; approximate total 0.3 g/kg) is widely used as an adjunctive treatment for patients with sepsis in Japan, but its efficacy in the reduction of mortality has not been evaluated. We investigated whether the administration of low-dose IVIgG is associated with clinically important outcomes including intensive care unit (ICU) and in-hospital mortality.

Methods

This is a post-hoc subgroup analysis of data from a retrospective cohort study, the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study. The JSEPTIC DIC study was conducted in 42 ICUs in 40 institutions throughout Japan, and it investigated associations between sepsis-related coagulopathy, anticoagulation therapies, and clinical outcomes of 3195 adult patients with sepsis and septic shock admitted to ICUs from January 2011 through December 2013. To investigate associations between low-dose IVIgG administration and mortalities, propensity score-based matching analysis was used.

Results

IVIgG was administered to 960 patients (30.8%). Patients who received IVIgG were more severely ill than those who did not (Acute Physiology and Chronic Health Evaluation (APACHE) II score 24.2 ± 8.8 vs 22.6 ± 8.7, p < 0.001). They had higher ICU mortality (22.8% vs 17.4%, p < 0.001), but similar in-hospital mortality (34.4% vs 31.0%, p = 0.066). In propensity score-matched analysis, 653 pairs were created. Both ICU mortality and in-hospital mortality were similar between the two groups (21.0% vs 18.1%, p = 0.185, and 32.9% vs 28.6%, p = 0.093, respectively) using generalized estimating equations fitted with logistic regression models adjusted for other therapeutic interventions. The administration of IVIgG was not associated with ICU or in-hospital mortality (odds ratio (OR) 0.883; 95% confidence interval (CI) 0.655–1.192, p = 0.417, and OR 0.957, 95% CI, 0.724–1.265, p = 0.758, respectively).

Conclusions

In this analysis of a large cohort of patients with sepsis and septic shock, the administration of low-dose IVIgG as an adjunctive therapy was not associated with a decrease in ICU or in-hospital mortality.

Trial registration

University Hospital Medical Information Network Individual Clinical Trials Registry, UMIN-CTR000012543. Registered on 10 December 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1764-4) contains supplementary material, which is available to authorized users.

[A Case of Squamous Cell Carcinoma of the Right Breast]

Squamous cell carcinoma(SCC)of the breast is rare and its clinicopathological features have not been fully elucidated. We report a patient with SCC of the right breast who underwent surgical resection. A 51-year-old woman was admitted to our hospital because of a right breast tumor. A round tumor with an irregular surface measuring about 3.0×2.5 cm was palpable in the ACarea of the right breast. No abnormal data were observed on laboratory examination, including tumor markers such as carcinoembryonic antigen(CEA), cancer antigen 15-3(CA15-3), breast cancer antigen 225(BCA225), and SCC antigen. Mammography showed a mass with spiculation measuring 2.7×1.7 cm. Ultrasonography also demonstrated a hypoechoic solid tumor with an irregular surface, measuring 2.6×1.6 cm. The pathological diagnosis of a needle biopsy specimen was a mixed type of SCC. We performed a typical right mastectomy with axillary and supraclavicular lymph node dissection. The tumor size was 2.8×1.8 cm. SCC was histologically diagnosed. There was partial invasion to other tissues. The dissected lymph nodes were not involved by carcinoma. Hormone receptors(estrogen and progesterone)and HER2 results were negative. The pathological Stage was II A(T2, N0, M0). The patient refused chemotherapy. However, her condition remains satisfactory without recurrence 2 years after surgery.

[Usefulness of Transnasal Decompression Tubes in Patients with Right-Sided Obstructive Colorectal Cancer]

PURPOSE

We performed this retrospective study to evaluate the usefulness of a transnasal decompression tube(long ileus tube)as a bridge to surgery in patients with right-sided obstructive colorectal cancer.

PATIENTS AND METHODS

There were 8 patients(5 men and 3 women, aged 64 to 85 years with a mean age of 75.9 years)who had undergone transnasal decom- pression in the last 10 years.

RESULT

1) The success rate of intubation was 100%(8/8). 2) Primary cancer location: Ascend- ing colon cancers were 37.5%(3/8)and right-sided transverse colon cancers 62.5%(5/8). 3) Decompression periods were from 1 to 43 days, with a mean period of 12.8 days. 4) Stage: Stage II was found at 12.5%(1/8), Stage II , III a, III b and IV were found at 25.0%(2/8), respectively. Advance Stages( III a, III b, and IV )were 75.0%(6/8). 5) Pathology: Well differentiated tubular adenocarcinoma(tub1)was at 37.5%(3/8)and moderately differentiated tubular adenocarcinoma (tub2)at 62.5%(5/8). 6) Operative procedures: Radical operation was performed in 6 cases except for 2 cases with stage IV disease. 7) Complications: Early complication were found in 37.5% of the cases(3/8). Wound infection was found in 12.5%(1/8), wound infection with rupture in 12.5%(1/8), and adhesive ileus in 12.5%(1/8). 8) Outcomes: The 5-year survival was 37.5%(3/8).

CONCLUSION

Transnasal tube decompression for right-sided malignant colorectal obstruction is useful for avoiding an emergency operation, and a single-stage operation can be performed in patients excluding Stage IV disease.

Effectiveness of cadaver-based educational seminar for trauma surgery: skills retention after half-year follow-up

Aim

In Japan, trauma surgery training remains insufficient, and on-the-job training has become increasingly difficult because of the decreasing number of severe trauma patients and the development of non-operative management. Therefore, we assessed whether a 1-day cadaver-based seminar is effective for trauma surgery training.

Methods

Data were collected from 11 seminars carried out from January 2013 to March 2014, including a 10-point self-assessment of confidence levels (SACL) for 21 surgical skills and an evaluation of the contents before, just after, and a half-year after the seminar. Statistical analysis was undertaken using the paired t-test at P < 0.0167.

Results

A total of 135 participants were divided into three groups based on experience and clinical careers. The SACL improved in all skills between before and just after the seminar, however, they decreased between just after and a half-year after the seminar. The SACL did not change significantly in all skills between just after and a half-year after the seminar in highly experienced and experienced group members belonging to an emergency center.

Conclusions

A cadaver-based seminar provided more self-confidence just after the seminar for participants at all experience levels. This effect was not maintained after a half-year, except in participants who can practice the skills at an emergency center. Practicing and participating in the seminar repeatedly is suggested to be effective for skills retention in trauma surgery.

Characteristics, treatments, and outcomes of severe sepsis of 3195 ICU-treated adult patients throughout Japan during 2011-2013

Severe sepsis is a major concern in the intensive care unit (ICU), although there is very little epidemiological information regarding severe sepsis in Japan. This study evaluated 3195 patients with severe sepsis in 42 ICUs throughout Japan. The patients with severe sepsis had a mean age of 70 ± 15 years and a mean Acute Physiology and Chronic Health Evaluation II score of 23 ± 9. The estimated survival rates at 28 and 90 days after ICU admission were 73.6 and 56.3 %, respectively.

Practice Guidelines for Primary Care of Acute Abdomen 2015

Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine, in collaboration with four other medical societies, launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines (all clinical questions and recommendations were shown in supplementary information). A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen. A total of 108 questions based on nine subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended. The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.

Relationships between pre-hospital characteristics and outcome in victims of foreign body airway obstruction during meals

OBJECTIVE

The purpose of this study is to determine the outcome of foreign body airway obstruction according to the initial actions taken for choking victims during meals.

METHODS

Our subjects were patients who became unresponsive or unconscious because of foreign body airway obstruction (FBAO) during meals in the presence of bystander witnesses. We investigated the associations between outcome and the following factors: age, gender, type of foreign body, chest compressions after the patient became unresponsive or unconscious, episode of cardiac arrest, efforts by a bystander to remove the foreign body, eating-related activities of daily living, time elapsed from the 119 call to arrival of emergency medical technicians (EMTs), and time elapsed from the 119 call to hospital arrival (primary endpoint).

RESULTS

Of the 138 patients enrolled during the study period, 35 (25.4%) received chest compressions by bystanders after becoming unresponsive or unconscious and 69 (50.0%) suffered cardiac pulmonary arrest. Chest compressions by a bystander after the victim became unresponsive or unconscious (p<0.0001) and no CPA (p<0.0001) were significantly related to good outcome. Chest compressions by a bystander were both associated with good neurological outcome (odds ratio, 10.57; 95% CI, 2.472-65.059, p<0.0001). No CPA after FBAO was another independent predictor (odds ratio, 50.512; 95% CI, 13.45-284.41; p<0.0001), but efforts to remove the foreign body before the arrival of EMTs did not affect outcome.

CONCLUSION

Chest compressions by a bystander, a support received by only 25% of the patients, proved to be essential for improved outcome for choking victims who became unresponsive or unconscious. Education for lay-rescuer response to choking might further improve overall outcome.

Saturated salt solution method: a useful cadaver embalming for surgical skills training

This article evaluates the suitability of cadavers embalmed by the saturated salt solution (SSS) method for surgical skills training (SST). SST courses using cadavers have been performed to advance a surgeon's techniques without any risk to patients. One important factor for improving SST is the suitability of specimens, which depends on the embalming method. In addition, the infectious risk and cost involved in using cadavers are problems that need to be solved. Six cadavers were embalmed by 3 methods: formalin solution, Thiel solution (TS), and SSS methods. Bacterial and fungal culture tests and measurement of ranges of motion were conducted for each cadaver. Fourteen surgeons evaluated the 3 embalming methods and 9 SST instructors (7 trauma surgeons and 2 orthopedists) operated the cadavers by 21 procedures. In addition, ultrasonography, central venous catheterization, and incision with cauterization followed by autosuture stapling were performed in some cadavers. The SSS method had a sufficient antibiotic effect and produced cadavers with flexible joints and a high tissue quality suitable for SST. The surgeons evaluated the cadavers embalmed by the SSS method to be highly equal to those embalmed by the TS method. Ultrasound images were clear in the cadavers embalmed by both the methods. Central venous catheterization could be performed in a cadaver embalmed by the SSS method and then be affirmed by x-ray. Lungs and intestines could be incised with cauterization and autosuture stapling in the cadavers embalmed by TS and SSS methods. Cadavers embalmed by the SSS method are sufficiently useful for SST. This method is simple, carries a low infectious risk, and is relatively of low cost, enabling a wider use of cadavers for SST.

Time from admission to initiation of surgery for source control is a critical determinant of survival in patients with gastrointestinal perforation with associated septic shock

Introduction

We developed a protocol to initiate surgical source control immediately after admission (early source control) and perform initial resuscitation using early goal-directed therapy (EGDT) for gastrointestinal (GI) perforation with associated septic shock. This study evaluated the relationship between the time from admission to initiation of surgery and the outcome of the protocol.

Methods

This examination is a prospective observational study and involved 154 patients of GI perforation with associated septic shock. We statistically analyzed the relationship between time to initiation of surgery and 60-day outcome, examined the change in 60-day outcome associated with each 2 hour delay in surgery initiation and determined a target time for 60-day survival.

Results

Logistic regression analysis demonstrated that time to initiation of surgery (hours) was significantly associated with 60-day outcome (Odds ratio (OR), 0.31; 95% Confidence intervals (CI)), 0.19-0.45; P <0.0001). Time to initiation of surgery (hours) was selected as an independent factor for 60-day outcome in multiple logistic regression analysis (OR), 0.29; 95% CI, 0.16-0.47; P <0.0001). The survival rate fell as surgery initiation was delayed and was 0% for times greater than 6 hours.

Conclusions

For patients of GI perforation with associated septic shock, time from admission to initiation of surgery for source control is a critical determinant, under the condition of being supported by hemodynamic stabilization. The target time for a favorable outcome may be within 6 hours from admission. We should not delay in initiating EGDT-assisted surgery if patients are complicated with septic shock.

Effects of bag-mask versus advanced airway ventilation for patients undergoing prolonged cardiopulmonary resuscitation in pre-hospital setting

BACKGROUND

There is no evidence that the advanced airway ventilation (AAV) method improves patient outcome in the pre-hospital cardiac arrest setting.

OBJECTIVE

The aim of this study was to estimate the effectiveness of AAV vs. bag-mask ventilation (BMV) for cardiopulmonary arrest (CPA) patients, when administered by a licensed emergency medical technician in the pre-hospital setting.

METHODS

The study used the database of patients who suffered out-of-hospital cardiogenic CPA from 2006 to 2007 in our hospital. Patient records were searched for the method of pre-hospital airway management (BMV or AAV) and the patient's outcomes were compared between groups. The primary endpoint was a favorable neurological outcome; the secondary endpoints were rate of return of spontaneous circulation (ROSC) and rate of admission to the intensive care unit (ICU).

RESULTS

A total of 355 CPA patients (156 BMV and 199 AAV) were retrospectively enrolled. There was no significant difference in demographics between the two groups. The transportation time exceeded 30 min in both groups. The overall ROSC rate and ICU admission rate were significantly higher in the AAV group (p = 0.0352 and p = 0.0089, respectively). The data showed that AAV (odds ratio 1.960; 95% confidence interval 1.015-3.785) resulted in a higher overall ROSC rate than BMV, but there were no significant differences in either the rate of pre-hospital ROSC or in favorable neurological outcome.

CONCLUSION

AAV may yield advantages over BMV in the overall rate of ROSC in CPA patients, but both approaches for airway management in this study resulted in a comparably favorable neurological outcome. Earlier ROSC would be required for improved overall outcome.

Valence Band Physics in Wurtzite GaN

We present a summary of recent progress towards the understanding of the valence-band physics in wurtzite GaN. Systematic studies have been performed on the strain dependence of the free exciton resonance energies by photoreflectance measurements using well-characterized samples. Analyzing the experimental data with the Hamiltonian appropriate for the valence bands, the values have been determined of the crystal field splitting, the spin-orbit splitting, the shear deformation potential constants, and the energy gap in the unstrained crystal. Discussions are given on the strain dependence of the energy gaps, of the effective masses, and of the binding energies for the free exciton ground states as well as on the valence band parameters. Using the obtained values and the generalized Elliott formula, the fundamental optical absorption spectra obtained experimentally were analyzed. The values of the elastic stiffness constants, which play a crucial role to determine the shear deformation potential constants, are also given.

Recombination of Localized Excitons in InGaN Single- and Multiquantum-Well Structures

Spontaneous emission mechanisms of InGaN single quantum well (SQW) blue and green light emitting diodes (LEDs) and multiquantum well (MQW) laser diode (LD) structures were investigated. Their static electroluminescence (EL) peak was assigned to the recombination of excitons localized at certain potential minima in the quantum well (QW). The transmission electron micrographs (TEM) indicated fluctuation of In molar fraction in the QWs. The blueshift of the EL peak caused by the increase of the driving current was explained by combined effects of the quantum-confinement Stark effect and band filling of the localized states by excitons.

A patient with Graves' disease who survived despite developing thyroid storm and lactic acidosis

A 56-year-old woman with Graves' disease presented with the complaints of diarrhea and palpitations. Physical examination and laboratory data revealed hypothermia and signs of mild hyperthyroidism, heart failure, hepatic dysfunction with jaundice, hypoglycemia, and lactic acidosis. The patient was diagnosed as having developed the complication of thyroid storm in the absence of marked elevation of the thyroid hormone levels, because of the potential hepatic and cardiac dysfunctions caused by heavy alcohol drinking. A year later, after successful treatment, the patient remains well without any clinical evidence of heart failure or hepatic dysfunction. Thyroid storm associated with lactic acidosis and hypothermia is a serious condition and has rarely been reported. Prompt treatment is essential even if the serum thyroid hormone levels are not markedly elevated. We present a report about this patient, as her life could eventually be saved.

Interleukin-8 production from human umbilical vein endothelial cells during brief hyperglycemia: the effect of tumor necrotic factor-alpha

BACKGROUND

This study evaluated the changes in chemokine interleukin (IL)-8 production from endothelial cells under various hyperglycemic conditions and investigated whether the hyperglycemia associated with the acute inflammatory response could enhance the IL-8 production from the endothelial cells.

MATERIALS AND METHODS

Human umbilical endothelial cells (HUVECs) were seeded at a concentration of 1 x 10(5) cells/well and cultured. The culture medium was replaced with Medium 199 containing various concentrations of glucose (final glucose concentration of culture medium was 100, 200, 300, 400, 500 mg/dL; n = 7 each) with or without 100 ng of tumor necrosis factor-alpha (TNF-alpha). After 12 or 24 h at 37 degrees C, the supernatants were collected from the cultures and stored at -80 degrees C until cytokine assay. IL-8 levels of the samples from the supernatants were quantified using a commercially available enzyme-linked immunosorbent assay kit.

RESULTS

The IL-8 production by the HUVECs was significantly higher in the high glucose culture than in the control culture (glucose concentration of 100 mg/dL) (P < 0.05). Moreover, the hyperglycemia associated with elevated TNF-alpha was found to enhance the level of IL-8 production by the HUVECs cultured at all glucose concentrations and over both time courses, compared to the control (P < 0.05).

CONCLUSIONS

In this study we observed a significant augmentation of IL-8 production by endothelial cells during short-term hyperglycemia, and a similar but significantly stronger augmentation was obtained through TNF treatment. These findings suggest that the hyperglycemia associated with acute inflammatory response after trauma may put the patients at high risk for secondary tissue damage.

Changes in glucagon kinetics and processing in patients with acute pancreatitis

BACKGROUND/AIMS

The kinetics of the pancreatic hormone glucagon in patients with acute pancreatitis have not been investigated as carefully as those of insulin, in spite of its crucial influence on energy metabolism. In the present study, we studied the kinetics of glucagon and glucagon-related peptides assessed by radioimmunoassay. Furthermore, the molecular forms of these peptides were examined using gel filtration chromatography, and the glucagon processes in the pancreas and intestine in the early stage in patients with acute pancreatitis were investigated.

METHODOLOGY

Fourteen patients with acute pancreatitis were enrolled in this study. Eight had severe pancreatitis (group S) and six had mild pancreatitis (group M). Ten healthy volunteers were also enrolled as the normal control (group C). Serum levels of glucagon and glucagon-related peptides were assessed on the second admission day in groups S and M, and in an early morning fasting state in group C, using glucagon non-specific N-terminal (glucagon-like immunoreactivity: GLI) and specific C-terminal (immunoreactive glucagon: IRG) radioimmunoassays. The molecular forms of these peptides were also estimated using gel filtration chromatography. We then discuss the glucagon processes based on these findings.

RESULTS

Serum GLI and IRG in groups S and M were significantly higher than those of group C (P < 0.01), while those in group S were also significantly higher than those in group M (P < 0.05). In all patients in groups S and M, except for only three in group S, a peculiar glicentin-like peptide (GLLP: MW about 8000) other than pancreatic glucagon was observed in IRG gel filtration chromatography, which was clearly absent from group C.

CONCLUSIONS

The kinetics and processing of glucagon in patients with acute pancreatitis were quite different from those of healthy subjects. In patients with acute pancreatitis, the peculiar processing of glucagon proceeded in the intestine quite differently from ordinary glucagon processing either in the pancreas or in the intestine, generating a peculiar GLLP.

Survivin inhibits apoptosis induced by TRAIL, and the ratio between survivin and TRAIL receptors is predictive of recurrent disease in neuroblastoma

PURPOSE

Novel treatment strategies for high-risk and disseminated neuroblastoma (NB) are actively sought because of the dismal prognosis of advanced stage disease. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is a recently identified member of the tumor necrosis factor family. TRAIL is capable of inducing apoptosis in multiple tumor cell types, with little or no cytotoxicity against normal cells.

EXPERIMENTAL DESIGN

We examined the activation and regulation of TRAIL-induced apoptosis in several human NB cell lines. The effect of TRAIL was examined in the context of TRAIL receptor (TRAIL-R) and survivin (an antiapoptotic protein) expression in the cell lines. The ratio of survivin/TRAIL-R messenger RNA was determined and evaluated as a marker of recurrent disease in patients with NB.

RESULTS

TRAIL induced apoptotic cell death of NB with variable sensitivities among the cell lines tested. Compared with a sensitive cell line (early passage NB16), the resistant cell lines (NB7 and late passage NB16) expressed lesser amounts of the death-inducing TRAIL-R1 and R2, and greater levels of survivin, an inhibitor of apoptosis. TRAIL sensitivity was enhanced in resistant cell lines by treating with etoposide that concomitantly increased TRAIL-R expression and diminished survivin expression. Survivin overexpression in a TRAIL-sensitive NB line (early passage NB16) rendered it less sensitive to treatment with TRAIL. Conversely, inhibiting survivin expression in NB3 by antisense oligonucleotides enhanced TRAIL sensitivity. A high survivin/TRAIL-R ratio accurately predicted risk for recurrent disease in primary tumor specimens tested.

CONCLUSIONS

These findings suggest that TRAIL therapy in combination with specific chemotherapeutic agents may represent an effective therapeutic strategy for NB. The cell's sensitivity to TRAIL is at least partially governed by both TRAIL-R and survivin expression, whereas the ratio between these 2 factors appears to have prognostic value in patients with this disease.

Induction and regulation of tumor necrosis factor-related apoptosis-inducing ligand/Apo-2 ligand-mediated apoptosis in renal cell carcinoma

The lack of effective therapy for disseminated renal cell carcinoma (RCC) has stimulated the search for novel treatments including immunotherapeutic strategies. However, poor therapeutic responses and marked toxicity associated with immunological agents has limited their use. The tumor necrosis factor family member tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)/Apo-2 ligand induces apoptosis in a variety of tumor cell types, while having little cytotoxic activity against normal cells. In this study the activation and regulation of TRAIL-induced apoptosis and TRAIL receptor expression in human RCC cell lines and pathologic specimens was examined. TRAIL induced caspase-mediated apoptotic death of RCC cells with variable sensitivities among the cell lines tested. Compared with TRAIL-sensitive RCC cell lines (A-498, ACHN, and 769-P), the TRAIL-resistant RCC cell line (786-O) expressed lesser amounts of the death-inducing TRAIL receptors, and greater amounts of survivin, an inhibitor of apoptosis. Incubation of 786-O with actinomycin D increased the expression of the death-inducing TRAIL receptors and, concomitantly, decreased the intracellular levels of survivin, resulting in TRAIL-induced apoptotic death. The link between survivin and TRAIL regulation was confirmed when an increase in TRAIL resistance was observed after overexpression of survivin in the TRAIL-sensitive, survivin-negative RCC line A-498. These findings, along with our observation that TRAIL receptors are expressed in RCC tumor tissue, suggest that TRAIL may be useful as a therapeutic agent for RCC and that survivin may partially regulate TRAIL-induced cell death.

The survivin:Fas ratio is predictive of recurrent disease in neuroblastoma

BACKGROUND/PURPOSE

Several clinical and biologic features of neuroblastoma (NB) are used to predict the risk of recurrent disease. The balance between antiapoptotic and proapoptotic factors within a tumor may affect its ability to survive. Survivin is an antiapoptotic factor expressed in highly proliferative NB, whereas Fas is a proapoptotic factor that portends a favorable prognosis. The authors determined whether the ratio of survivin to Fas (S:F ratio) is predictive of recurrent disease in patients with NB. The authors previously have shown the S:F ratio is predictive of recurrent disease in pediatric renal tumors.

METHODS

The authors quantified the levels of 9 different apoptotic mRNA species using Rnase Protection assay (RPA, Riboquant, PharMingen, San Diego, CA). Twenty-eight primary tumor specimens were evaluated from patients with ganglioneuroma (n = 3), ganglioneuroblastoma (n = 2), and neuroblastoma (n = 23) from tumors of all clinical stages obtained at the time of diagnosis. mRNA levels were calculated as a percentage of L32 for each specimen assayed, and positive expression was assumed to be greater than 10% of L32.

RESULTS

Survivin was expressed in 90% of tumors that went on to recur and only in 27.7% of those that were cured. The S:F ratio was significantly greater in tumors that went on to recur (n = 10) compared with those from patients that were cured (n = 18) (median S:F ratio, 3.3 v 0.75; P =.0002, Wilcoxon rank-sum test). A cutoff ratio of 2.3 was highly predictive of tumor recurrence irrespective of clinical stage of disease (area under ROC curve = 0.906). Sensitivity was 80% (CI, 44.4% to 97.5%), specificity was 94.4% (CI, 72.7% to 99.9%), positive predictive value was 88.9% (CI, 51.8% to 99.7%), and negative predictive value was 89.5% (66.9% to 98.7%). Twenty-five of 28 (89.3%) tumor ratios were correct in predicting outcome.

CONCLUSIONS

The survivin:Fas ratio in primary tumors may be used to predict the risk for recurrent disease in patients with NB. The S:F ratio appears to be a more sensitive predictor of recurrent disease than survivin expression alone. Determining this ratio may not only be helpful in guiding follow-up of patients with NB, but also may aid in stratifying patients for more aggressive therapeutic strategies.

The inhibitor of apoptosis protein survivin is associated with high-risk behavior of neuroblastoma

BACKGROUND/PURPOSE

Apoptotic factors inducing or preventing cell death may intrinsically govern the behavior of some tumors. Survivin is a recently described member of the inhibitor of apoptosis protein (IAP) family, that is expressed in a cell cycle-dependent manner and is found in tumors of unfavorable histology. This study examines the presence of several apoptotic factors, including survivin, in neuroblastoma (NB) tumors. Clues to survivin's function in NB are provided by examining its association with behavior and cell dynamics in tumors and cell lines.

METHODS

Expression of a panel of apoptosis factors were quantified in 15 NB and related tumors before chemotherapy and in 3 NB cell lines (NB7, NB10, and NB16). Survivin and other apoptotic factors, as well N-myc amplification in primary tumors was correlated with recurrent disease and outcome. Proliferation rate, apoptosis assays, cell cycle analysis, and drug- or immune-mediated cell death were assessed in cell lines and evaluated in the context of differential survivin and apoptosis gene expression.

RESULTS

All 7 tumors that went on to recur expressed survivin, whereas expression was absent in all 8 tumors that went into remission. N-myc was amplified in 4 (57.1%) of the 7 recurrent tumors. Of the 8 tumors that were cured, Fas was expressed in 3 (38%), TRAIL-R1 in 6 (75%) and tumor necrosis factor (TNF)-R1 in 8 (100%), whereas these pro-apoptotic receptors were present in only 1 (14%), 1 (14%), and 4 (57%) of the 7 tumors that went on to recur, respectively. Of the 3 cell lines, NB10 expressed the least survivin, displayed the lowest proliferation index, and had the fewest number of cells in the G2/M (mitotic) phase of the cell cycle. Furthermore, NB10 also was most sensitive to TNF-related apoptosis-inducing ligand (TRAIL) or etoposide-induced cell death.

CONCLUSIONS

In primary NB tumors, survivin expression was associated with tumors of high risk and unfavorable prognosis, whereas pro-apoptotic receptor expression was more abundant in tumors of favorable prognosis. In this small series, survivin expression appeared to be more predictive of recurrent disease than N-myc amplification. In cell lines, survivin expression was cell cycle dependent, and its expression was associated with greater proliferation rates and greater resistance to drug- or immune-mediated cell death. Survivin expression may become a useful prognostic marker in NB and could be a potential target for the treatment of this tumor. J Pediatr Surg 36:1785-1791.

Increased soluble CD23 molecules in serum/saliva and correlation with the stage of sialoectasis in patients with primary Sjögren's syndrome

OBJECTIVE

We examined the soluble CD23 (sCD23) molecules in sera and saliva from patients with Sjögren's syndrome.

METHODS

The determination of sCD23 and other soluble molecules were made by the enzyme-linked immunosorbent assay.

RESULTS

The amounts of sCD23 in the sera/saliva were significantly increased in the patients compared to the controls and the levels were significantly correlated with sialoectasis.

CONCLUSION

The findings suggest that increased sCD23 molecules in saliva from patients with Sjögren's syndrome may reflect active sialoectasis.

[Reproducibility of the topographic parameters of the optic disk with the scanning laser tomograph]

The scanning laser tomograph was used to measure the optic disk topography in the left eye of five normal volunteers and five open angle glaucoma patients during the same day. We studied the reproducibility of 7 topographic parameters with the coefficient of variation (CV) and coefficient of reliability (CR) from topographic images of the scanning laser tomograph. The mean CV of the topographic parameters was 8.1 +/- 3.3% (range: 5.3-15.0%) and the mean CR of the topographic parameters was 91.8 +/- 7.6% (range: 78.6-98.4%) in normal eyes. In glaucoma eyes, the mean CV was 7.2 +/- 3.7% (range: 4.4-15.0%) and the mean CR was 84.8 +/- 7.5% (range: 73.4-95.3%), respectively. The results showed that the scanning laser tomograph has good reproducibility for clinical use in optic disk measurements.