Makoto Onodera

Balloon-occluded retrograde transvenous obliteration for gastric varices: the relationship between the clinical outcome and gastrorenal shunt occlusion

BackgroundThe rupture of gastric varices is associated with high mortality rate. Balloon-occluded retrograde transvenous obliteration (B-RTO), a minimally invasive procedure that was introduced in the mid-1990s, has been widely accepted in Japan. Several reports have indicated that B-RTO yields satisfactory results; however, few reports have discussed the recurrence of gastric varices after this therapy. The purpose of this study is to retrospectively evaluate the technical aspects of B-RTO and the recurrence of gastric varices after treatment with this procedure.MethodsB-RTO was performed in 47 patients with gastric varices, who were at a risk of variceal ruptures and who may or may not have had a history of variceal bleeding. We injected a sclerosing agent into the gastric varices for 30-60 minutes. To evaluate the therapeutic efficacy of the technique, we obtained contrast-enhanced computed tomography (CT) scans 5 days after B-RTO. As a general rule, if the gastric varices did not appear thrombosed, we repeated the procedure 7 days after the first procedure.ResultsB-RTO was a technical success in 37 patients. It was performed once in 26 patients, twice in 6 patients, thrice in 2 patients, and 4 times in 3 patients. Contrast-enhanced CT scans obtained after B-RTO showed thrombosed gastrorenal shunts in 29 patients and patent gastrorenal shunts in 8 patients. The gastric varices recurred in 2 patients who had patent gastrorenal shunts. The overall cumulative relapse-free rate of gastric varices was 90% at 5 years after B-RTO.ConclusionsB-RTO is an effective treatment modality for gastric varices. Moreover, obliteration of the gastrorenal shunt as well as the gastric varices appears to be important for the treatment of gastric varices.

Risk factors for early re-bleeding and associated hospitalization in patients with colonic diverticular bleeding

The annual incidence of colonic diverticular bleeding is increasing, but treatments are not yet well established. Here we aimed to identify the risk factors for early re‐bleeding and to determine the associated duration of hospitalization.

Factors associated with severe effects following acute glufosinate poisoning

Abstract Context. In acute glufosinate poisoning, sudden respiratory arrest and convulsion can occur after a latent period of 4–60 h. There is still no factor that accurately predicts the occurrence of these symptoms. Objective. To elucidate the predictors of severe effects following acute glufosinate poisoning. Materials and methods. This study is a retrospective observational case series. The subjects were 16 patients who had acute glufosinate poisoning. They were divided into a group with respiratory arrest or convulsion during hospitalization (severe group) and a group without (non-severe group). The following characteristics (or predictors) were compared between the groups: age, sex, calculated amount of glufosinate (volume of ingested poison (glufosinate-containing herbicide) × glufosinate concentration of the product), time duration from poison ingestion to arrival at our hospital, use of gastric lavage, use of whole bowel irrigation, Glasgow Coma Scale, laboratory parameters, PaO2/FiO2 ratio (P/F ratio), shock index, and presence or absence of systemic inflammatory response syndrome (SIRS) on arrival. Results. The P/F ratio was significantly lower in the severe group than in the non-severe group (median, 287.5 vs. 409.0; P = 0.049). The receiver operating characteristic (ROC) curve was plotted for the predictor of increasing severity based on the P/F ratio. The area under the curve was 0.714, and the optimal cutoff point for increasing severity was 374.0. The sensitivity was 75.0%, specificity of 71.4%, and accuracy of 75.0%. The shock index was significantly higher (median, 0.52 vs. 0.41; P = 0.031). Significantly more patients had SIRS in the severe group than in the non-severe group (P = 0.015). Logistic regression analysis was performed with a backward elimination procedure. SIRS was selected as the independent predictor of increasing severity (odds ratio, 29.810; 95% confidence interval, 1.011–878.952; P = 0.049). Discussion and conclusion. Severe effects following acute glufosinate poisoning were associated with two positive SIRS criteria. A low P/F ratio may be useful for predicting the occurrence of respiratory complications.

1H-magnetic resonance spectroscopy indicates damage to cerebral white matter in the subacute phase after CO poisoning

Objective The authors examined whether 1H-magnetic resonance spectroscopy (MRS) can identify damage to the centrum semiovale in the subacute phase after CO exposure. Methods Subjects comprised 29 adult patients who were treated with hyperbaric oxygenation within a range of 4–95 h (mean 18.7 h) after CO exposure. Subjects were classified into three groups according to clinical behaviours: Group A, patients with transit acute symptoms only; Group P, patients with persistent neurological symptoms; and Group D, patients with ‘delayed neuropsychiatric sequelae’ occurring after a lucid interval. MRS of bilateral centrum semiovale was performed 2 weeks after CO inhalation for all patients and 13 healthy volunteers. The mean ratios of choline-containing compounds/creatine (meanCho/Cr) and N-acetylaspartate/Cr (meanNAA/Cr) for bilateral centrum semiovale were calculated and compared between the three CO groups and controls. Myelin basic protein (MBP) concentration in cerebrospinal fluid was examined at 2 weeks to evaluate the degree of demyelination in patients. Results MBP concentration was abnormal for almost all patients in Groups P and D, but was not abnormal for any Group A patients. The meanCho/Cr ratios were significantly higher in Groups P and D than in Group A. No significant difference in meanNAA/Cr ratio was seen between the three pathological groups and controls. A significant correlation was identified between MBP and meanCho/Cr ratio. Conclusions These results suggest that the Cho/Cr ratio in the subacute phase after CO intoxication represents early demyelination in the centrum semiovale, and can predict chronic neurological symptoms.

Clinical and toxicological findings of acute intoxication with synthetic cannabinoids and cathinones

Reporting of the analytical and clinical findings of synthetic cannabinoids and cathinones is essential in carrying out a complete clinical assessment of new psychoactive substances.

Hematoma of the iliopsoas muscle due to thrombocytopenia resulting from the administration of a third-generation cephalosporin

Dear Editor, We herein report a case of drug-induced thrombocytopenia (DIT) due to a cephem antibiotic that was caused by both immunological mechanisms and decreased platelet production in the bone marrow. A 69-year-old female was admitted to the hospital due to pyrexia and swelling of the right thigh. In her previous history, right putamen hemorrhaging accompanied by aneurysms in both middle cerebral arteries had been detected 5 years earlier, and she had been treated with antihypertensive agents without any side effects until the present day. Based on a diagnosis of cellulitis of the right thigh, ceftriaxone sodium was administered at 2 g/day. One week after the treatment, with a chief complaint of abdominal pain, the patient had tarry stool and, thereafter, fell into a state of shock. In the abdominal CT examination, a hematoma of the right iliopsoas muscle was detected (Fig. 1). The upper gastrointestinal endoscope detected only petechiae in the stomach. The platelet count had been 150,000/μL at admission but had decreased to 1,000/μL in 1 week, with petechiae all throughout the body. The hemoglobin concentration had decreased to 9.4 g/dL, the LDH level had increased to 640 U/L, and the CPK level had increased to 488 U/L. Platelet-associated IgG (PAIgG) showed an abnormally high level at 6,400 ng/10 cells (normal values are from 9 to 25). The blood culture and urine culture were negative for any findings indicating infection or DIC. Marrow aspiration detected no megakaryocytes, indicating drug-induced marrow suppression. The platelet level recovered to 81,000/μL on day 4 of hospitalization after a platelet transfusion of 80 units and subsequently increased to a normal value. The hematoma of the right iliopsoas muscle reduced in size over time. The patient was discharged from the hospital on day 20. DIT is defined as a pathological condition in which the platelet count in the peripheral blood becomes 50,000/μL or less due to a drug and spontaneous bleeding varying from petechia, purpura, and gingival hemorrhage to lifethreatening spontaneous intracranial hemorrhage [1]. Based on its pathogenesis, DIT is classified between immune DIT and non-immune DIT. Immunological mechanisms are involved in the destruction of platelets in the peripheral blood, including hapten-dependent antibody formation, drug–glycoprotein complex antibody formation, autoantibody formation, ligand-induced binding site creation, drug-specific antibody formation, and immune complex-mediated antibody formation [2]. If platelet destruction occurs via immunological mechanisms, then the marrow megakaryocytes reactively increase, and in many cases, PAIgG also increases [3]. At

A Case of Secondary Aortoesophageal Fistula Inserted a Covered Self-Expanding Esophageal Stent to Control Gastrointestinal Bleeding

A 73-year-old man presented with melena. After a thorough workup including esophageal endoscopy, computed tomography scans, and esophagography, the diagnosis of secondary aortoesophageal fistula was made. Two years previously, he had undergone endovascular stent-graft repair for the dissection of his descending thoracic aorta. Because of the generally poor condition of the patient and the high risk of any aggressive surgical intervention, we inserted a covered self-expanding esophageal stent on postadmission day 18. Esophagography after insertion did not show any evidence of a leak of contrast medium. Despite treatment with antibiotics, he developed sepsis and expired on day 52, but rebleeding did not occur in this period. We consider insertion of a covered self-expanding esophageal stent as a feasible option in the management of secondary aortoesophageal fistula in high-risk patients.

Interleukin-18 levels reflect the severity of acute pancreatitis

Abstract To examine the influence of interleukin (IL)-18 in acute pancreatitis from the points of view of the severity of the disease, presence of the complication of MODF and the prognosis, 17 patients with acute pancreatitis were enlisted. The IL-18 and TNF-α levels in the serum were determined by enzyme-linked immunosorbent assay. The levels of IL-18 were 4.3±5.3 pg/ml in the mild group, 18.7±67.1 pg/ml in the moderate group, and 269.6±2482.1 pg/ml in the severe group. The IL-18 levels increased significantly, corresponding to the severity of the disease. The group in which the complication of multiple organ dysfunction syndrome (MODS) developed showed significantly higher IL-18 levels than that in which this complication did not develop. The IL-18 levels in the survivor group were 132.0±130.7 pg/ml, and those in the nonsurvivor group were 3028.6±480.8 pg/ml, the levels being significantly higher in the nonsurvivor group. Significant correlations were observed between the maximum serum IL-18 and TNF-α levels. Significant correlations were observed between the total bilirubin and IL-18 levels. The results suggest that IL-18 may be used as a good indicator of severity of acute pancreatitis and that involved in the development of liver dysfunction in acute pancreatitis.

Utility of the Measurement of Carboxyhemoglobin Level at the Site of Acute Carbon Monoxide Poisoning in Rural Areas

Objective. This study examined the hypothesis that correlations exist between the carbon monoxide exposure time and the carboxyhemoglobin concentration at the site of carbon monoxide poisoning, using a pulse carbon monoxide oximeter in rural areas or the carboxyhemoglobin concentration measured at a given medical institution. Background. In previous studies, no definitive relationships between the arterial blood carboxyhemoglobin level and the severity of carbon monoxide poisoning have been observed. Method. The subjects included patients treated for acute carbon monoxide poisoning in whom a medical emergency team was able to measure the carboxyhemoglobin level at the site of poisoning. We examined the relationship between the carboxyhemoglobin level at the site of poisoning and carbon monoxide exposure time and the relationships between the arterial blood carboxyhemoglobin level and carbon monoxide exposure time. Results. A total of 10 patients met the above criteria. The carboxyhemoglobin levels at the site of poisoning were significantly and positively correlated with the exposure time (rs = 0.710, p = 0.021), but the arterial blood carboxyhemoglobin levels were not correlated with the exposure time. Conclusion. In rural areas, the carboxyhemoglobin level measured at the site of carbon monoxide poisoning correlated with the exposure time.

Toxicokinetics of the Synthetic Cathinone α-Pyrrolidinohexanophenone

Synthetic cathinones inhibit monoamine transporters, such as serotonin, norepinephrine, and dopamine transporters, and act on the central nervous system via increasing synaptic concentrations of monoamines. These compounds, which are highly addictive and potentially poisonous, are new psychoactive substances. In this study, we investigated the toxicokinetics of the synthetic cathinone, α-pyrrolidinohexanophenone (α-PHP), and assessed the relationship between the toxicokinetics and the long-term clinical symptoms induced by α-PHP in a male patient. The patient (39 years old) suddenly started uttering inarticulate words and demonstrating incomprehensible behavior in his house, and was brought to the emergency department of Iwate Medical University hospital. He presented with psychotic symptoms, such as hallucinations and delusion; however, his vital signs were normal. The hallucinations and delusion improved by the third day of hospitalization. Toxicological analysis was performed using liquid chromatography-tandem mass spectrometry with QuEChERS extraction. α-PHP was detected in his serum at a concentration of 175 ng/mL on his arrival at the hospital. His serum concentrations of α-PHP were serially determined and their natural logarithms were plotted against time after arrival. Although serum concentrations at early time points were lacking, the obtained curve was consistent with a two-compartment model and indicated a serum elimination half-life of 37 h. The long-lasting psychotic symptoms induced by synthetic cathinones appear to be correlated with their toxicokinetic characteristics, such as their long half-lives. Finally, interpreting the toxicokinetics of synthetic cathinones may provide useful information for the toxicological assessment of new psychoactive substances for forensic and clinical purposes.