Displaced Intra-Articular Calcaneal Fractures: Evaluation of Clinical and Radiological Outcome Following Open Reduction and Internal Fixation with Locking Branched Calcaneal Plate

Background An introduction of the World Health Organization Surgical Safety Checklist (WHO SSC) is essential to promote surgical safety. Objective To obtain country-specific information regarding the checklist in a leading medical institution in Nepal. Method The present research was a cross-sectional study with a survey conducted among healthcare professionals working in the operation theatre at the Tribhuvan University Teaching Hospital (TUTH) in Kathmandu, Nepal. A questionnaire was distributed to 150 healthcare professionals working in the operating theatre. Responses to the questionnaire were analysed descriptively and regression analyses used to identify factors associated with awareness of the checklist. Result In total, 127 healthcare professionals participated in the study, of whom 118 (92.9%) had been aware of the WHO SSC. A substantial proportion of participants (108, 91.5%) were not satisfied with the prevailing practice whereby the checklist was not routinely used during surgery. Lack of appropriate training was the most prevalent barrier to the checklist use (72, 67.9%), followed by unwillingness of staff to use the checklist (54, 50.9%), and lack of experience (42, 39.7%). The mean score on the survey was 6.0 out of 10. Regarding the results of the regression model on survey scores, surgeons had higher scores compared to nurses (unadjusted coefficient 0.80, 95% CI 0.20-1.40). Conclusion Most of the healthcare professionals were aware of the WHO SSC, however multiple barriers to the checklist use were identified. It is important to establish an effective use of WHO SSC in the operation theatre.

Mycobacterium avium genotype is associated with the therapeutic response to lung infection

Factors that can interfere with the successful treatment of Mycobacterium avium lung infection have been inadequately studied. To identify a potent predictor of therapeutic responses of M. avium lung infection, we analyzed variable number tandem repeats (VNTR) at 16 minisatellite loci of M. avium clinical isolates. Associations between the VNTR profiling data and a therapeutic response were evaluated in 59 subjects with M. avium lung infection. M. avium lung infection of 30 subjects in whom clarithromycin-containing regimens produced microbiological and radiographic improvement was defined as responsive disease, while that of the remaining 29 subjects was defined as refractory disease. In phylogenetic analysis using the genotypic distance aggregated from 16-dimensional VNTR data, 59 M. avium isolates were divided into three clusters, which showed a nearly significant association with therapeutic responses (p 0.06). We then subjected the raw 16-dimensional VNTR data directly to principal component analysis, and identified the genetic features that were significantly associated with the therapeutic response (p <0.05). By further analysis of logistic regression with a stepwise variable-selection, we constructed the highest likelihood multivariate model, adjusted for age, to predict a therapeutic response, using VNTR data from only four minisatellite loci. In conclusion, we identified four mycobacterial minisatellite loci that together were associated with the therapeutic response of M. avium lung infections.

Clinical evaluation of the QuantiFERON-TB Gold test in patients with non-tuberculous mycobacterial disease

OBJECTIVE

To evaluate the clinical usefulness of the QuantiFERON TB-2G (QFT-2G) test in patients with non-tuberculous mycobacterial (NTM) disease without a previous history of tuberculosis (TB).

METHODS

The study consisted of 214 patients with NTM disease who satisfied the diagnostic guidelines of the American Thoracic Society.

RESULTS

The causative microorganism was Mycobacterium avium in 83 patients, M. intracellulare in 80, M. kansasii in 33, M. marinum in 12, M. szulgai in 3, M. abscessus in 2 and M. chelonei in 1. The positive response rate of QFT-2G test result was 2% in 163 patients with M. avium-intracellulare complex (MAIC) disease, 52% in 33 with M. kansasii disease, 58% in 12 with M. marinum disease, 33% in 3 with M. szulgai disease, 0% in two with M. abscessus disease and 0% in one with M. chelonei disease. The positivity of the QFT-2G test was 52% in patients with NTM disease, thought to be because NTM possesses common M. tuberculosis-specific antigens.

CONCLUSIONS

Although QFT-2G may be a useful diagnostic method to differentiate TB from MAIC disease, there are several problems to be resolved before it can be used as a diagnostic method for NTM disease (M. kansasii disease), including the determination of the positive cut-off level for QFT-2G test.

Clinical evaluation of QuantiFERON TB-2G test for immunocompromised patients

The usefulness of the tuberculin skin test (TST) and the QuantiFERON TB-2G (QFT-TB) test were compared in immunocompromised patients. The subjects consisted of 252 immunocompromised patients who were clinically suspected of tuberculosis (TB) infection between April 2005 and December 2006. Regarding the underlying diseases, 74 subjects had malignant diseases, 72 were undergoing immunosuppressive treatment, 52 had diabetes mellitus, 50 had chronic renal failure and four had HIV infection. While the positive rate of the QFT-TB test for the diagnosis of TB infection (TB disease or latent TB infection) was 78.1%, that of TST for TB infection was 50.0%. The QFT-TB test was significantly better than TST. However, 32 (13%) patients had an indeterminate QFT-TB result. Indeterminate findings were significantly more frequent in patients receiving immunosuppressive treatment (28%), especially with lymphocytopaenia in the peripheral blood, than in those who had other underlying diseases. While TST-positive and QFT-TB test-negative results were recognised in immunocompromised patients with bacille Calmette-Guérin vaccination or nontuberculous mycobacterial disease, TST-negative and QFT-TB test-positive results were recognised in immunocompromised patients with a past history of TB infection. It was concluded that the QuantiFERON TB-2G test is a more useful diagnostic method for tuberculosis infection than tuberculin skin test for immunocompromised patients suspected of tuberculosis disease. However, because the results of the QuantiFERON TB-2G test show an indeterminate response for patients receiving immunosuppressive treatment, especially for those with lymphocytopaenia due to severe underlying diseases, care must be taken in the interpretation of the QuantiFERON TB-2G test for these patients.

Cystic adenomyosis with florid glandular differentiation mimicking ovarian malignancy

We report a case of cystic adenomyosis, presenting as a huge exophytic cystic mass with florid glandular differentiation. MR findings of the mass mimicked ovarian carcinoma associated with endometriosis. The presence of signal voids bridging the uterus and tumour should suggest a mass of uterine origin. Hyperintense protuberance in a hypointense loculus on T(2) weighted images may suggest benign disease. However, surgical exploration and resection is still required to exclude an ovarian malignancy.

[Occurrence of BOOP outside radiation field after radiation therapy for small cell lung cancer]

We report a case of bronchiolitis obliterans organizing pneumonia (BOOP) that occurred outside the radiation field after radiation therapy for small cell lung cancer. A 74-year-old woman received chemotherapy and a total of 60 Gy of radiation therapy to the right hilum and mediastinum for small cell carcinoma of the suprahilar area of the right lung. Radiation pneumonitis developed within the radiation port 3 months after the completion of radiation therapy. She complained of cough and was admitted 7 months after completion of the radiation therapy. Chest radiography and computed tomography demonstrated peripheral alveolar opacities outside the radiation field on the side contralateral to that receiving the radiation therapy. Bronchoalveolar lavage showed that the total cell count was increased, with a markedly increased percentage of lymphocytes. Transbronchial lung biopsy revealed a histologic pattern consistent with BOOP. Treatment with corticosteroids resulted in rapid improvement of the symptoms and complete resolution of the radiographic abnormalities of the left lung. Although some cases of BOOP following radiation therapy for breast cancer have been reported, none of BOOP after radiation therapy for lung cancer have appeared in the literature.

Thin-section CT features of intrapulmonary lymph nodes

PURPOSE

The objective of this study was to evaluate CT findings of pathologically proven intrapulmonary lymph nodes (IPLNs) and discuss the utility of thin-section CT and contrast-enhanced CT.

METHOD

CT findings of 18 nodules in 14 patients with pathologically proven IPLNs were reviewed. CT scanning of the whole lung was performed contiguously with slice thickness of 10 mm. In addition, a helical scan with slice thickness of 2 mm was performed in nine patients, focusing on the nodule. Contrast-enhanced helical CT was performed in four patients, and the utility of thin section CT and contrast-enhanced CT was investigated.

RESULTS

One patient had three nodules, 2 patients had two nodules, and the remaining 11 patients had a solitary nodule. All nodules were located below the level of the carina and within 15 mm of the pleura. In one case, conventional CT revealed the nodule 20 mm away from the pleura; however, the nodule attached to the major fissure was clearly revealed on thin-section CT. The size of the nodules was < or =15 mm, and the shape was round (n = 8), oval (n = 9), or lobulated (n = 1) with sharp border. One nodule demonstrated a spiculated border due to a surrounding pulmonary fibrosis on conventional CT; however, thin-section CT showed precisely a sharp border. The lobulated shape of one case histopathologically reflected a hilus of lymph node. On contrast-enhanced helical CT, all four nodules were enhanced and the degree enhancement was 36-85 HU (median 66.6 HU).

CONCLUSION

In current times, IPLNs are not uncommon lesions. We should consider IPLN in the differential diagnosis of solitary or multiple pulmonary nodules in the peripheral field and below the level of the carina. Thin-section CT showed precisely the border or relation between IPLNs and the surrounding structure. It was difficult to distinguish between IPLNs and malignant nodules from the degree of enhancement on contrast-enhanced CT. On thin-section and contrast-enhanced CT, the findings of IPLNs are not necessarily specific. Therefore, strict observation on CT is necessary; in certain cases that are increasing in size, video-assisted thoracic surgery should be considered because of their location.

Clinical analysis of community-acquired pneumonia in the elderly

OBJECTIVE

To evaluate the clinical features, etiology, and outcome of patients over 65 years old hospitalized for community-acquired pneumonia.

PATIENTS

Eighty-four patients (50 males, 34 females) hospitalized for community-acquired pneumonia in Kawasaki Medical School Kawasaki Hospital between April 1998 and March 2000.

RESULTS

Most of the patients had respiratory symptoms or signs, but over one-third also had atypical symptoms of pneumonia such as dyspnea, consciousness disturbance, and gastrointestinal symptoms. The causative microorganisms were identified in 48% of these patients. Streptococcus pneumoniae (13%), respiratory viruses (13%), Haemophilus influenzae (8%) and Mycobacterium tuberculosis (8%) were frequently identified, but Mycoplasma pneumoniae was less frequently noted in the elderly. Double infection was recognized in 19 % and a combination of some virus and bacteria in 13%. Treatment consisted of the administration of second or third generation cephalosporin antibiotics intravenously, because antibiotics had already been preadministered in 39%. The prognosis was poor (mortality rate 9%) for the elderly with community-acquired pneumonia despite mechanical ventilation in 8%.

CONCLUSIONS

Although the range of microorganisms causing community-acquired pneumonia differed slightly from that in previous reports; namely, lower frequency of Chlamydia pneumoniae and Legionella pneumophila, it is suggested that the initial antibiotic treatment should always cover S. pneumoniae and H. influenzae. In addition, since a prevalence of virus infections related to the increase in community-acquired pneumonia in the elderly was found in this study, the routine use of influenza vaccine and pneumococcal vaccines in the elderly is recommended to reduce the high mortality rate.

Gynecologic malignancies accompanied by benign hormone-dependent diseases

OBJECTIVE

To investigate the correlation between benign gynecologic diseases and hormone-dependent malignancies such as endometrial carcinoma in postmenopausal women.

DESIGN

We retrospectively analyzed the prevalence of myoma uteri and adenomyosis uteri in 136 cases of endometrial carcinomas. We used 222 uterine prolapse cases as controls.

RESULTS

The results showed that 21.6% and 9.9% of healthy postmenopausal women (control) had myoma uteri and adenomyosis uteri, respectively, after the cessation of menses. However, postmenopausal women with endometrial carcinomas had a 1.5- to 2-fold higher prevalence, respectively, for myoma uteri and adenomyosis uteri as compared with the postmenopausal control women.

CONCLUSION

There was a higher prevalence of myoma uteri and adenomyosis uteri in postmenopausal patients with endometrial carcinomas than in the control population.

[Clinical analysis of patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents--including a comparative study of an infectious group with monomicrobial agents and an infectious group with unknown agents]

We clinically analyzed 83 patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents who we have treated during the past 15 years. A comparative study among three groups; an infectious group with polymicrobial agents (83 cases), an infectious group with monomicrobial agents (335 cases), and an infectious group with unknown agents (599 cases) was performed. The results were as follows; (1) The highest percentage of patients were elderly and bedridden. (2) Striking atypical pneumonic symptoms, including dyspnea, consciousness disturbance, gastrointestinal symptoms and hypotension (shock) were present. (3) Laboratory findings of poor nutritional conditions, including decreases in serum protein, albumin, and cholineesterase, and hypoxia remarkably increased. (4) The prognosis was poor because the mortality rate (15.7%) was higher. (5) There were two polymicrobial agents for 75 patients and three agents for 8 patients. The coupling of polymicrobial agents was most frequent in five patients with Haemophilus influenzae + MSSA and five with H. influenzae + respiratory virus. These results suggest that the patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents had clinical features and causative microorganisms resembling those of elderly patients with community-acquired pneumonia. We recommended that treatment with antibiotics for them was adequate if the treatment resemble that of elderly patients.

[Clinical analysis of community-acquired pneumonia and pulmonary tuberculosis in the elderly and advances in treatment]

We treated 510 elderly case (over 65 years old) among 1,017 patients with community-acquired pneumonia and 60 similar cases among 112 patients with pulmonary tuberculosis in Kawasaki Medical School Kawasaki Hospital during approximately the past 15 years. These were compared with non-elderly cases (below 65 years old). In the elderly cases with community-acquired pneumonia, atypical clinical symptoms or physical signs were frequent and the mortality rate was high because of severe underlying diseases, and poor general and nutritional conditions. Regarding a prospective study of 84 elderly cases with community-acquired pneumonia during the past two years, S. pneumoniae, Respiratory virus, Gram-negative bacilli, H. influenzae, M. Tuberculosis were frequently isolated. In addition, mixed viral and bacterial infections, which were frequently noted during the winter, were significantly related to the increased frequency of community-acquired pneumonia. In treating elderly cases with community-acquired pneumonia, immunization therapy (e.g., influenza vaccine), second cephalosporin and/or macrolide antimicrobial agents for outpatients with mild pneumonia, and carbapenem and/or macrolide antimicrobial agents for hospitalized patients with moderate or severe pneumonia were most effective. The number of elderly cases with pulmonary tuberculosis has recently increased and the recognition of 10 cases was delayed because of a low percentage of positive smears, but no resistance to antituberculosis drugs have been observed. Regarding the treatment of pulmonary tuberculosis, fluoroquinolone and rifamycin derivative antibiotics have been developed as antituberculosis drugs with strong antituberculous activity. However, due to the high percentage of adverse effects in elderly patients, careful treatment with desensitization therapy for antituberculosis drugs is considered important.

Breast conservation for huge-sized locally advanced breast cancer: a case report

A 35-year-old woman with locally advanced stage IIIB breast cancer (medullary carcinoma) 12 cm in diameter underwent neoadjuvant chemotherapy consisting of three courses of intraarterial infusion [adriamycin (ADR), mitomycin (MMC), cisplatin (CDDP), 5-fluorouracil (5FU)] and four cycles of systemic chemotherapy (ADR, epirubicin, cyclophosphamide, MMC, CDDP) for three months. The tumor markedly diminished after the first course of intraarterial infusion chemotherapy, with a 3-cm tumor remaining after the completion of preoperative administration. Pathologically complete response was noted in specimens resected following breast conservation surgery. Postoperative radiotherapy was added and adjuvant chemohormonal therapy was continued for two years. The patient is alive without recurrence and has been able to conserve the breast for the past eight years, neoadjuvant chemotherapy including intraarterial infusion enabled breast conservation treatment even for huge-sized locally advanced breast cancer.

Intraarterial infusion chemotherapy and radiotherapy with or without surgery for patients with locally advanced or recurrent breast cancer

We analyzed response, side effects, and local control rates of a multimodal treatment consisting of intraarterial infusion chemotherapy (IAIC) and radiotherapy with or without surgery for patients with locally advanced or recurred breast cancer. Thirty-three patients, clinically diagnosed as stage IIB in 1, IIIA in 2, IIIB in 12, IV in 18, were treated from 1991 to 1998. Twenty-five were primary and eight were recurrent cases after surgery. IAIC started as initial treatment up to three times maximum. In most cases, doxorubicin 50 mg, cisplatin 50 mg, and mitomycin 10 mg were infused in the subclavian and/or internal mammary artery. After IAIC, patients in primary cases underwent radical mastectomy or breast conservation surgery, after radiotherapy at a total dose of 50 Gy/25 fractions/5 weeks with a boost of 10 Gy. In recurrent cases, a full dose of radiotherapy was delivered. Clinical objective and complete response rates were 78% and 9% after IAIC. Despite a high rate of residual positive margin (67%) or clinically residual carcinoma, local recurrence developed only in 2 patients (6%) and local control rates at 5 years were calculated as 89%. Bone marrow suppression was frequent, and skin vesiculation (15%) and ulceration (9%) were experienced after IAIC. Skin ulcer (6%), brachial plexus neuropathy (3%), and radiation pneumonitis (3%) occurred as late toxicity. IAIC was effective as an induction treatment and radiotherapy played a role of local control for patients with locally advanced or recurrent breast cancer.

Mismatched clinicopathological response after concurrent chemoradiotherapy for thoracic esophageal cancer

We have been treating patients with operable thoracic esophageal cancer according to our own protocol. It includes the initial concurrent chemoradiotherapy (CRT) followed by continuous CRT or surgery. Patients with good response to initial chemoradiotherapy were allowed to continue chemoradiotherapy, whereas the others were treated with surgery. However, there were two cases which showed discrepancies in the clinicopathological response. Both patients received initial chemoradiotherapy, including two courses of cisplatin (100-120 mg), 5-fluorouracil (750-1000 mg for 4 days) and radiation (44-50 Gy). On completion of the initial chemoradiotherapy, all diagnostic imaging modalities including barium swallow, esophagoscopy, endoscopic ultrasonography and thoracic computed tomography strongly implicated residual tumor with a reduction rate of 40-50%. The patients underwent radical esophagectomy 15-20 days after initial chemoradiotherapy. Pathological specimens only revealed thickening of the esophageal wall due to inflammatory change without residual carcinoma. These facts suggest the current limitations of diagnostic images in evaluating the response to chemoradiotherapy.

[Clinical analysis of patients with community-acquired pneumonia requiring hospitalization classified by age group]

We classified 1017 patients with community-acquired pneumonia requiring hospitalization experienced in Kawasaki Medical School Kawasaki Hospital during the past 15 years into five age groups (< or = 54 years old, 55-64 years old, 65-74 years old, 75-84 years old, > or = 85 years old). With particular emphasis on the elderly patients, we then compared the clinical and microbiological findings in the five groups. The results were as follows; (1) Half of patients in the over 85 years old group were bed-ridden. (2) The proportion receiving antibiotics before hospitalization decreased with age. (3) There were striking atypical pneumonic symptoms, such as dyspnea and consciousness disturbance in the two age groups over 75 years old. (4) Hypotension (shock) increased with age. (5) Markers of nutritional conditions, such as serum protein, albumin, cholinesterase, and hypoxia remarkably increased in the two age groups over 75 years old. (6) There were no significant differences in the isolation rate of etiological microorganisms. (7) The number of polymicrobial agents in the < or = 54 years old group was lower than that in the other age groups. (8) Mycoplasma pneumoniae was most significantly higher in < or = 54 years old group, Haemophilus influenzae in patients 55-64 years old, and Streptococcus pneumoniae in both 65-74 and 75-84 years old groups. (9) The isolation rate of MSSA, gram-negative bacilli such as Klebsiella pneumoniae, Pseudomonas aeruginosa, respiratory viruses increased with age. (10) The amount of sepsis increased with age. (11) The prognosis was poor in the two groups over 75 years old because the mortality rate (over 10%) was higher that for the other age groups.

Fibrous tumor of the breast in a postmenopausal woman receiving estrogen

Fibrous tumor of the breast is a rare, benign stromal proliferation with atrophy of the epithelial component. Almost all patients who develop fibrous tumors are premenopausal. An unusual example of fibrous tumor of the breast is reported in a 62-year-old postmenopausal woman. The mass, first noted 1 year previously, progressively enlarged over the year. The patient noted a history of taking exogenous estrogens for 10 years. Intense estrogen administration during the year of enlargement may be associated with accelerated growth of the tumor. In addition, positive nuclear staining for estrogen receptor antibodies in stromal cells was demonstrated by immunohistochemical methods.

[A case of rheumatoid lung disease in which lung involvement preceded arthritis]

A 75-year-old man was admitted because of dyspnea on exertion and diffuse pulmonary interstitial shadows. An open lung biopsy revealed unclassified interstitial pneumonia. The abnormal shadow subsided spontaneously. Three years later, however, rheumatoid arthritis developed with a simultaneous relapse of interstitial pneumonitis, which was alleviated by steroid therapy. We report here the rheumatoid lung disease that preceded the onset of arthritis, together with a review of the literature.

[Comparison of community-acquired pneumonia in relation to influenza A and RS virus infections]

We experienced 142 cases with community-acquired pneumonia between April 1998 and March 2000. By measuring the titers of respiratory viruses for these cases, we were able to identify acute phase infections of influenza A virus in 10 cases and RS virus in 6 cases and determined that there was an increase in community-acquired pneumonia during both winter seasons. Thereafter we compared the clinical features of community-acquired pneumonia with regard to these two types of virus infection by dividing the patients into two groups, both of which frequently included in the elderly. In the influenza virus group, such general symptoms as high fever, headache and general fatigue were dominant. Common bacteria were isolated in nine cases with mixed infection; four of them with Streptococcus pneumoniae. In the RS virus group, there were fewer general symptoms and common bacteria were isolated in four cases with mixed infection; three with Haemophilus influenzae. The severity of the illness was greater in the Influenza virus group; i.e.) three cases required mechanical ventilation and two of these three cases died. In the RS virus group, on the other hand, the prognosis was good because no mechanical ventilation was required and there were no deaths. Influenza vaccination is especially important for the elderly, because the epidemiology of the influenza virus groups showed none had a history of influenza vaccination in this study.

Rapidly progressive pneumonia due to Aeromonas hydrophila shortly after near-drowning

An 87-year-old woman died of rapidly progressive pneumonia due to Aeromonas hydrophila shortly after a near-drowning event. Autopsy showed necrotizing pneumonia and postmortem cultures of both blood and lung revealed the organism. Fulminant pneumonia should be considered in patients of a near-drowning event.

[Desensitization therapy for allergic reactions of antituberculous drugs--evaluation of desensitization therapy according to the guideline of the Japanese Society for Tuberculosis]

We prospectively evaluated the effectiveness of desensitization therapy for cases showing side-effects to antituberculous drugs (Isoniazid and Rifampicin) according to the guideline proposed by the Treatment Committee of the Japanese Society for Tuberculosis. Nineteen patients (23-88 years old, male 9, female 10) who had experienced adverse effects after receiving antituberculous drugs and underwent desensitization therapy between August 1998 and March 2000 were studied. Underlying diseases were 14 cases of pulmonary tuberculosis, 2 cases of cervical tuberculous lymphadenitis, 1 case of pulmonary atypical mycobacteriosis, 1 case of pulmonary tuberculosis and tuberculous pleuritis, 1 case of pulmonary tuberculosis and tuberculous lymphadenitis. The regimens of treatment for tuberculosis were INH + RFP + EB in 8 cases, INH + RFP + EB + PZA in 7 cases, INH + RFP + SM in 2 cases, INH + RFP + SM + PZA in 1 case, and INH + RFP in 1 case. Adverse reactions were 8 cases of eruption, 7 cases of drug fever, 3 cases of drug fever and eruption, and 1 case of drug fever and cervical lymphadenopathy. The causative drugs suggested from DLST or the clinical course were RFP in 17 cases and INH in 8 cases. The clinical effect of desensitization therapy for these antituberculous drugs was good in 14 out of the 17 cases (82%) for RFP, and in 6 out of 8 cases (75%) for INH. The effectiveness rate of the present desensitization therapy according to the guideline of the Japanese Society for Tuberculosis was almost equal to that of previous desensitization therapy, and the clinical results were almost same in present and previous studies despite the different methods of administration of the antituberculous drugs.

[Viral infection related to the appearance of acute bacterial respiratory tract infections]

To investigate what viruses are related to acute bacterial respiratory tract infections, we prospectively evaluated 113 cases with respiratory tract infections (always accompanying by purulent sputum) experienced between July 1998 and March 2000. Acute viral infections were detected in 25 cases (22%); 10 cases of influenza A virus and 6 cases of respiratory syncytial (RS) virus. The epidemiology of the influenza A virus and RS virus was mainly identified as from December to February in both winter seasons. A bacteriological examination of sputum cultures isolated 12 cases of Streptococcus pneumoniae and 10 cases of Haemophilus influenzae during the same periods and mixed infections of both viruses and bacteria were recognised in 16 cases (14%). These results suggest a significantly high percentage of mixed infections of both viruses and bacteria. However, it was unknown whether the patients with acute bacterial respiratory infections had been infected with viruses prior to the bacterial infections. The frequency of appearance of respiratory tract infections tended to increase with the seasonale epidemiology of viral infections.

[Desensitization therapy for antituberculous drugs]

We retrospectively evaluated the effectiveness of desensitization therapy for antituberculous drugs (Rifampicin and Isoniazid) in 28 cases (29 episodes) with adverse reactions to these drugs. Desensitization therapy for RFP was performed in 23 cases (24 episodes) with administration of a first dose of 1-150 mg and a final dose of 300-450 mg for 1-29 days. The success rate of this therapy was 79% (19 of 24 episodes). Desensitization therapy for INH was performed in 12 cases with administration of a first dose of 2.5-100 mg and a final dose of 200-400 mg for 3-25 days. The success rate of this therapy was 83% (10 of 12 cases). Based on a comparative study of cases between successful and unsuccessful desensitization to RFP and INH it was concluded that there were no significant differences with regard to allergic history, adverse effects and their periods of appearance, the first dose and final dose of administration and the interval of administration, starting periods of the desensitization therapy and the periods of appearance of adverse effects due to this therapy. We evaluated desensitization therapy for two antituberculous drugs (RFP and INH) for tuberculous patients for whom the use of such drugs was restricted because of adverse effects, and we found it is a useful treatment, showing a high rate of success (80%).

Diffuse intrahepatic recurrence after resection of hepatocellular carcinoma

BACKGROUND/AIMS

An early diffuse type in the pattern of the postoperative intrahepatic recurrence of hepatocellular carcinoma has been recognized. The purpose of this study was to elucidate risk factors for diffuse recurrence of hepatocellular carcinoma.

METHODOLOGY

The subjects involved in the present study were 114 patients with hepatocellular carcinomas resected in Tenri Hospital during the past 12 years. Univariate analysis was used for retrospective determination of the factors related to diffuse recurrences after surgery in 10 cases among 114 patients.

RESULTS

The risk factors linked to diffuse recurrence were microscopical portal infiltration (P < 0.01), elevated alpha-fetoprotein (more than 1000 ng/mL) (P < 0.05), the absence of preoperative transcatheter arterial embolization (P < 0.01), and two or more segmentectomies of the liver (P < 0.01). Six of 10 patients with microscopical portal infiltration and elevated alpha-fetoprotein (more than 1000 ng/mL) had diffuse recurrence (P < 0.01). Six of 8 patients with two or more segmentectomies without preoperative TAE had diffuse recurrence (P < 0.01).

CONCLUSIONS

When patients with the diagnosis of operable hepatocellular carcinoma have portal infiltration and elevated alpha-fetoprotein (more than 1000 ng/mL), two or more segmentectomies of the liver without preoperative transcatheter arterial embolization should be avoided.

[Transitional pattern of the clinical features of patients with pulmonary tuberculosis in a community hospital]

To determine changes in the clinical features of recent patients with pulmonary tuberculosis in a community hospital without restricted tuberculosis wards, the clinical findings of 112 patients with pulmonary tuberculosis (containing miliary tuberculosis) during the past 15 years were compared by dividing the patients into three groups, each encompassing a five-year period. Recently, the number of patients with pulmonary tuberculosis was found to be increasing in a community hospital. In particular, the percentages of elderly patients and smear positive patients have increased. However, because of the improving awareness on tuberculosis, we have diagnosed TB cases correctly on admission and tended to perform the appropriate treatment. The comparative study between pulmonary tuberculosis patients diagnosed at the outpatients department and diagnosed after admission indicated that the patients diagnosed after admission showed pneumonia-like infiltrative shadows without cavity formation and lower smear positivity for tubercle. Fortunately, resistance to antituberculous drugs of isolated tubercle bacilli in our community hospital has not yet increased and the prognosis of the cases proved to be good when the appropriate treatment was performed at an early stage.

MR findings of subarachnoid dissemination of a pituitary adenoma

Although pituitary adenoma is a benign tumour, subarachnoid dissemination occurs rarely. We describe a case of pituitary adenoma with subarachnoid dissemination. After the third operation for pituitary adenoma, an extraaxial mass was demonstrated on MR images. On T1 and T2 weighted images, the signal intensities of the extraaxial mass were similar to those of the primary pituitary adenoma. On dynamic contrast T1 weighted images, the time-intensity curve of the extraaxial mass, which showed early and persistent signal intensity, was also similar to that of the primary pituitary adenoma. These MR findings are considered to reflect the similar vascularity and stroma of the extraaxial mass and the primary pituitary adenoma.

[Occurrence of BOOP outside radiation field after tangential radiation therapy for breast carcinoma]

We report three cases of bronchiolitis obliterans organizing pneumonia (BOOP) that occurred outside the radiation field after radiation therapy using tangential fields for breast carcinoma. All patients complained of a cough between 14 and 20 weeks after completion of radiation therapy. Fever also developed in two of the three. Chest radiography and computed tomography demonstrated peripheral alveolar opacities outside the radiation field on the same side as the radiation therapy. Laboratory data showed an increased level of C-reactive protein and an increased erythrocyte sedimentation rate. Bronchoalveolar lavage showed an elevated total cell count with a very high percentage of lymphocytes. Transbronchial lung biopsy revealed a histologic pattern consistent with BOOP. Treatment with corticosteroids resulted in rapid clinical improvement and complete resolution of the radiographic abnormalities. This pulmonary disorder appears to be induced by radiation, especially when a tangential field is employed for breast carcinoma, though the etiology has not been fully investigated. It is important to be aware of this type of pulmonary complication in patients given radiotherapy for breast carcinoma.

[Clinical analysis of nursing home-acquired pneumonia in a community hospital]

To clarify the characteristic features of nursing home-acquired pneumonia in our community hospital, we performed a clinical analysis of 86 patients with nursing home-acquired pneumonia. The patients were divided into young and elderly groups. In the young group cerebral palsy was the underlying disease. In the elderly group, it was cerebrovascular attack. Although there were no differences in ADL, the nutritional condition of the young group was comparatively good, the isolated microorganism consisted of mostly Mycoplasma pneumoniae and the prognosis was good. The elderly group where the nutritional condition was poor, the patients were detected by non-respiratory symptoms and risk factors such as obvious episodes of aspiration led us to be concerned about the risk factors for nursing home-acquired pneumonia. The microorganism isolated from the sputum of the elderly group was frequently a multi-drug resistant microorganism such as Methicillin-resistant Staphylococcus aureus (MRSA) and polymicrobial infection. Their prognosis was poor despite treatment with multiple antibiotics. In the comparative study between survivors and non-survivors in the elderly group, risk factors such as hypotension, consciousness disturbance, the extension of infiltration shadows, respiratory failure, multiple organ failure and metabolic acidosis were influenced for the prognosis, but the isolated microorganisms and the antimicrobial agents were not concerned.

[A case with infectious mononucleosis-like syndrome caused by human herpes virus-6 infection]

A 26-year-old female was admitted because of multiple fractures in lower extremities. While in the hospital, she developed a high fever and generalized skin eruption. Physical examination revealed bilateral cervical lymphadenopathy and mild hepatosplenomegaly. The white cell count was 11,200 with 11% atypical lymphocytes. Serum GOT, GPT, LDH were markedly elevated. Infectious mononucleosis was suspected, but the serological test for EB virus did not show evidence of acute EB virus infection. Anti-HSV, CMV, hepatitis A virus antibody titers also did not show significant change during the coarse. The serological test for HHV-6 only showed increased titer of IgM and IgG antibodies. Rapidly elevated IgG antibody titer was indicative of reactivation of HHV-6. So, she was diagnosed as mononucleosis-like syndrome caused by HHV-6, probably reactivated infection. Her symptoms gradually disappeared during a month.

[Clinical analysis of community-acquired pneumonia requiring hospitalization in a community hospital--comparison of elderly and non-elderly patients]

A comparative study of 890 patients with community-acquired pneumonia requiring hospitalization in a community hospital was performed. The patients were divided into an elderly patient group and a non-elderly patient group. The elderly patients with community-acquired pneumonia exhibited frequent atypical symptoms such as dyspnea, consciousness disturbance and complication of shock, and also were frequently in a poor nutritional condition. The causative microorganism was isolated in 40.8% of the elderly patients and in 44.0% of the non-elderly patients. Polymicrobial agents were detected frequently in the elderly patients. Streptococcus pneumoniae (19.4%), MSSA (16.8%), Klebsiella pneumoniae (15.1%) and Haemophilus influenzae (15.0%) were frequently isolated from the sputum of the elderly patients, while Mycoplasma pneumoniae (25.2%), H. influenzae (15.0%), S. pneumoniae (12.2%) and MSSA (10.2%) were frequently isolated from that of the non-elderly patients. Regarding treatment with antibiotics, therapy with a single antibiotic therapy, such as cephem or carbapenem was carried out for the elderly patients, while new quinolone or tetracycline was administered to the non-elderly patients. Although the treatment with antibiotics was adequate according to the guidelines of the American Thoracic Society, the prognosis was poor; i.e.) in the elderly patients an efficacy rate of 74.3% and a mortality rate of 9.5%. In the non-elderly patients, the prognosis was good; i.e.) an efficacy rate of 88.0% and a mortality rate of 1.7%. These results suggest that the most important factors affecting the prognosis were the general condition of elderly patients and delay in an adequate diagnosis and treatment because of atypical clinical findings.

Struma ovarii: MRI findings

We describe the MRI findings in three cases of struma ovarii. In all three cases, MRI showed a multilocular cystic mass with a variable signal intensity within loculi. Some loculi or small cysts within septations showed low signal intensity on T1 weighted images and very low signal intensity on T2 weighted images, corresponding pathologically to gelatinous colloid material in large follicles. In one case, with Gd-DTPA enhanced T1 weighted images, the thick septations and locally thickened wall showed marked enhancement, corresponding microscopically to thyroid tissue.

[Clinical analysis of pulmonary tuberculosis in association with corticosteroid therapy]

In the last five years, five patients (three males and two females) among a total of 162 patients (3.1%) ranging from 63 to 79 years old developed pulmonary tuberculosis during the long-term corticosteroid therapy. The underlying diseases of these cases were pulmonary fibrosis in two, polyarteritis nodosa in one, RPGN + pulmonary bleeding in one, and mycosis fungoides in one. The total corticosteroid dose used until the clinical diagnosis of pulmonary tuberculosis was 1.16 g to 5.60 g and the term of administration was two to nine and a half months. Other immunosuppressive drugs were administered to two patients. Though chemoprophylaxis with INH was done in two patients for three months, it was impossible to prevent the development of pulmonary tuberculosis. Since almost all patients except one complained no symptoms at the onset, the follow-up with chest roentgenograms seemed to be most important during corticosteroid therapy, and in fact, four patients were detected by the follow-up. Antituberculous chemotherapy was effective in four patients but was not carried out for one patient due to the delay in the diagnosis. Careful clinical observation, such as by chest roentgenograms, seems to be appropriate for the early diagnosis and treatment of pulmonary tuberculosis in patients on corticosteroid therapy.

[A case of pulmonary infectious disease due to Mycobacterium szulgai]

A 49-year-old male was admitted to our hospital complaining of cough and general fatigue. There was nothing unusual about his past history, and he has been healthy. On admission, a chest roentogenogram revealed an infiltrative shadow with a cavity in the left middle and lower fields. Because the acid fast staining of a bronchoscopic specimen was positive for mycobacteria, he was transferred to another hospital to be treated as pulmonary tuberculosis. Culture tests of multiple specimens were positive, and were identified as Mycobacterium szulgai, and the case was diagnosed as pulmonary atypical mycobacteriosis caused by M. szulgai. He was treated with isoniazid, rifampicin and ethambutol daily, but because of side effects, such as drug eruptions, all drugs were stopped. However, his clinical symptoms and infiltration shadow improved gradually. We described a rare case of pulmonary disease with Mycobacterium szulgai infection appearing in a healthy male without underlying diseases.

CT findings of BALTOMA

OBJECTIVE

To review the CT findings of BALTOMA, a low-grade malignant lymphoma originating from bronchus-associated lymphoid tissue (BALT).

METHODS

The CT findings, symptoms, and clinical courses of BALTOMA in five patients were reviewed. The specimens obtained at operation were investigated, and the pathological findings were compared with the CT findings.

RESULTS

There were no symptoms in four patients and normal laboratory data in all patients. One patient who complained of general malaise underwent surgery under suspicion of lung carcinoma. Four patients were observed from 4 months to 7 years and 1 month under the diagnosis of organizing pneumonia or chronic inflammatory processes. On CT images a localized lesion was seen in four cases, while multiple lesions were seen in one case. Attenuation of the lesions was between 39.15 and 60 HU on nonenhanced CT. Lesions were homogeneously enhanced by contrast material. The margins of the lesion were clearly demarcated by interlobular septa in one portion and were unclear in the other portion in all cases. Air bronchograms were seen in four cases. CT angiogram signs were seen in three of four cases in which contrast study was performed. There was no lymphadenopathy, pleural changes, or invasion to other organs. The pathological investigation revealed small lymphocytes that showed monoclonality in all cases.

CONCLUSIONS

Awareness of the CT findings of BALTOMA can help to avoid misinterpreting BALTOMA as chronic inflammation and/or lung carcinoma. When a slowly progressive chronic pneumonia is being followed up, transbronchial lung biopsy and immunoglobulin staining of lymphocytes should be recommended for the correct diagnosis.

[Clinical analysis of pneumonia in the elderly in a community hospital--comparison of community-acquired pneumonia and nosocomial pneumonia]

We experienced 530 elderly cases with pneumonia among 930 patients with pneumonia in Kawasaki Medical School Kawasaki Hospital between April 1986 and September 1998. Clinical analysis of all these patients and a comparison of one group consisting of 418 patients with community-acquired pneumonia and another group composed of 112 patients with nosocomial pneumonia were performed. In all of the elderly patients with pneumonia, respiratory symptoms and inflammatory findings were less frequent, but were frequent for those in poor general and nutritional condition. The causative microorganism was isolated in 42% of these patients. Streptococcus pneumoniae, MSSA and Klebsiella pneumoniae were frequently isolated from the sputum of the patients with community-acquired pneumonia, while Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Methicillin-sensitive Staphylococcus aureus (MSSA) were frequently isolated from that of nosocomial pneumonia patients. Mycoplasma pneumoniae, Chlamydia pneumoniae and some viruses were less frequent for patients in both groups. Although many intravenous antibiotics, such as cephem or carbapenem were administered to patients in both groups, the prognosis was relatively good for those with community acquired pneumonia but was extremely poor for those with nosocomial pneumonia despite mechanical ventilation or steroid pulse therapy for many patients.

[Clinical analysis of the prognosis of severe pneumonia requiring mechanical ventilation]

To determine which factors are important in predicting the outcome of patients with severe pneumonia requiring mechanical ventilation, we compared 43 surviving pneumonic patients with 37 non-surviving pneumonic patients. The following results were obtained. The following characteristics were noted in the non-surviving patients as compared with surviving patients; 1. a worsening of performance status in the background, 2. presence of physical signs such as hypotension and trachycardia, 3. abnormal laboratory data such as leukocytosis, lymphocytopenia, hypoalbuminemia, hepatorenal dysfunction and metabolic acidosis, 4. presence of massive pulmonary infiltrations on chest roentgenograms, 5. a prevalence of resistant microorganisms for many antibiotics such as MRSA (Methicillin resistant Staphylococcus aureus). These results suggest that the most important factor affecting the prognosis of patients with severe pneumonia requiring mechanical ventilation may by the condition of the host and of the microorganisms rather than antibiotic treatment.

[Three cases of pneumonia due to mixed infection of bacteria and Mycoplasma pneumoniae]

We reported three cases of pneumonia due to mixed infection of bacteria (2 cases: Streptococcus pneumoniae, 1 case: methicilline-sensitive Stapholococcus aureus) and Mycoplasma pneumoniae. Increased serum antibody titers of M. pneumoniae were noted in all cases. They were a 36-year-old-female with bronchial asthma, a 74-year-old-male with old pulmonary tuberculosis and a 82-year-old-male with chronic bronchitis. All cases had fever, productive cough with purulent sputum and coarse crackle by auscultation. Leukocytosis was noted in 2 cases. Chest X-ray films showed dense consolidation in all cases, 2 cases were cured by administration of cephems and 1 case was cured by administration of carbapenems and minocycline.

Assessment of myometrial invasion at the invasion site of an endometrial carcinoma by ultrasonography along with an intrauterine catheter

OBJECTIVES

To evaluate by transvaginal ultrasonography (TVU) the thickness of the intact myometrium at the presumed tumor-origin site and to establish criteria for a half myometrial invasion.

METHODS

A total of 19 successive patients with endometrial cancer who were treated between January 1, 1997, and January 31, 1998, participated in this study. TVU mode B with and without the use of an intrauterine silicon catheter was performed.

RESULTS

Using a catheter, the origin site was correctly detected in 15 cases (79%). The best criterion for half myometrial invasion was a 6-mm thickness of the intact myometrium at the origin site. The sensitivity/specificity/accuracy of TVU with the use of a catheter in cases with the correct estimated origin site, were 1.00/0.67/0.86 for myometrial invasion < 1/2, and 0.67/1.00/0.86 for myometrial invasion > or = 1/2.

CONCLUSION

It is of value to use 6-mm as the criterion for the thickness of the intact myometrium at the estimated tumor-origin site in connection with TVU with the use of a catheter for preoperatively assessing half myometrial invasion.

[Pulmonary metastatic malignant phyllodes tumor showing multiple thin walled cavities]

A 52-year-old woman who had undergone a partial mastectomy 1 year earlier because of benign phyllodes tumor was admitted because of dry cough and abnormal chest radiograph findings. Chest computed tomograms demonstrated multiple thin-walled cavities and nodules. Clinical examinations and transbronchial biopsy specimens failed to provide a conclusive diagnosis. However, the pulmonary thin-walled cavities enlarged, and a nodular shadow revealed cavitary formation. An open lung biopsy was performed to diagnose the pulmonary lesions. Although biopsy specimens disclosed the infiltration of poorly differentiated adenocarcinoma cells in pleura and pulmonary parenchyma, no primary site was detected. The patient did not respond to systemic chemotherapy (CDDP and VP-16), and died of respiratory failure due to advanced pulmonary metastasis. Autopsy demonstrated marked tumor invasion of the lungs, myocardium, and bone. We analyzed malignant cells in lung tissues at autopsy by immunohistochemistry, and found identical malignant cells in surgical samples obtained during the patients earlier mastectomy. A diagnosis of pulmonary metastasis from malignant phyllodes tumor of the breast was made. Thin walled cavitary lesions from malignant phyllodes tumor are rare; however, pulmonary metastasis of malignant phyllodes tumor should be considered one disease that exhibits thin-walled cavities as a radiographic manifestation.

[Neoadjuvant chemotherapy for advanced cervical cancer]

Twenty-five patients with advanced cervical cancer (IIb-IVa) were treated with neoadjuvant chemotherapy followed by radical hysterectomy or radiotherapy. According to the evaluation by MRI, complete response was achieved in 2 cases and partial response in 17 cases. Eventually the response rate was 76%. The response rate was higher in squamous cell carcinomas (85%) than adenocarcinomas or adenosquamous carcinomas (67%). The histological effect is superior in squamous cell carcinomas than adenocarcinomas or adenosquamous carcinomas. Radical hysterectomy was performed in 5 cases of 11 (45%) stage III-IVa cervical cancers. There was no correlation between tumor size and response to NAC. NAC therapy may be useful therapy in advanced cervical cancers, especially squamous cell carcinomas.

Serum C-reactive protein as a prognostic factor in patients with epithelial ovarian cancer

OBJECTIVE

It is well known that the serum level of Interleukin-6 (IL-6) correlates with the level of C-reactive protein (CRP). The purpose of this study is to determine the significance of CRP as a prognostic factor in epithelial ovarian cancer.

STUDY DESIGN

The present study is comprised of 120 patients with epithelial ovarian cancer from 1985 to 1992. In this study, CRP levels above 50 mg/l were considered high CRP. Univariate and multivariate analyses were performed to identify clinicopathological variables associated with poor survival.

RESULTS

The serum CRP value was significantly associated with the volume of ascites (P = 0.000004). Univariate analysis showed that the FIGO stage, primary tumour diameter, size of residual tumour, histologic grade, volume of ascites and high serum level of CRP were significant prognostic factors. Cox's multivariate proportional hazard model showed that histologic grade was the most important prognostic factor (P = 0.0026). FIGO stage and volume of ascites were also independent factors for 5-year survival (P = 0.0310 and P = 0.0216, respectively). However, the serum CRP value was not an independent prognostic factor.

CONCLUSION

CRP is an adverse prognostic factor in univariate analysis, but not in multivariate analysis.

[A case with chronic active EB virus infection accompanied with pulmonary candidiasis]

A 44-year-old woman with a history of intermittent fever for several years was admitted because of burn on her leg. On admission, she had hepatosplenomegaly and fever. Antibiotic therapy was started for bacterial infection of the burn. She lost her appetite and IVH was started. During the treatment, high fever appeared and chest X-ray films showed multiple nodular infiltrates throughout both lung fields. Candida albicans was isolated from IVH catheter culture and pulmonary candidiasis was suspected. Her fever and lung involvements were successfully treated with fluconazole. During the course, serum anti-EB-VCA-IgG antibody persisted at a high titer and anti-EBNA antibody remained negative. EB virus DNA was detected in the peripheral blood and bone marrow. Thus, she was diagnosed as chronic active EB virus infection.

[Clinical analysis of foreign patients with tuberculosis found in Chugoku-Shikoku area]

In this study, we investigated 45 foreign patients who had been diagnosed as having tuberculosis in Chugoku-Shikoku area during the past 12 years. Regarding regional characteristics, in Hiroshima prefecture an epidemic of tuberculosis was experienced among patients coming from South America, but antituberculous therapy was performed for 87% of the patients because of the high coverage of the health insurance scheme. But in Okayama prefecture, most of the patients were female and came from Asian countries, such as, the Philippines. Antituberculous therapy was not performed for nine patients because of no coverage of the health insurance scheme. In the other prefectures, only a few cases of tuberculosis were experienced, but in Yamaguchi prefecture two of three foreign patients were multidrug-resistant tuberculosis.

[Nosocomial pneumonia experienced in a community hospital]

To clarify the characteristic features of nosocomial pneumonia in a community hospital, we performed a clinical analysis of 147 patients (155 episodes) with nosocomial pneumonia. The following results were obtained. 1, Regarding the risk factors for nosocomial pneumonia, factors such as the patient whose age was over 65 years, a duration of admission of over one month, performance status 4 and underlying respiratory diseases associated with the appearance of nosocomial pneumonia. 2, The causative microorganism isolated from the sputum of the patient with nosocomial pneumonia was frequently a multi-drug resistant microorganism such as Methicillin-resistant Staphylococcus aureus (MRSA). 3, regarding treatment, although several antibiotics were administered for a long time, mechanical ventilation was used on 31% of the patients, and steroid pulse therapy was carried out on 24%. The clinical efficacy was poor with a 50% mortality rate. The reason why treatment of nosocomial pneumonia was difficult is thought to be been related to the general condition of these inpatients and to the appearance of a multi-drug resistant, polymicrobial microorganisms.