Myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) associated glomerulonephritis is commonly diagnosed in elderly patients with acute kidney injury (AKI). Prompt diagnosis and rapid initiation of appropriate therapy are essential to avoid the development of ANCA-associated vasculitis, which can be a life- and organ-threatening disease. We report a rare case of a 91-year-old male with a high MPO-ANCA titer, who took allopurinol, and showed no symptoms for >20 months, following which sudden AKI and severe bronchial asthma necessitated hemodialysis and steroid administration. Chronically elevated ANCA titers should be examined for causes and followed up to limit the risk of subsequent disease development.

[Objective]There are few reports of inpatients who received acupuncture treatment in departments of internal medicine in Japan. The aim of this analysis is to clarify such information by reviewing patients who received acupuncture treatment during admission to our department of internal medicine at Gifu University Hospital. Our department is organized into three subdepartments of cardiology, respirology, and nephrology.
[Methods]We surveyed the chief complaint for acupuncture treatment, basic disease for admission and the number and period of acupuncture treatment of inpatients who received acupuncture treatment in our department from July 2004 through March 2007.
[Results]Two hundred and sixty-six patients received acupuncture treatment and they had 429 symptoms.
The chief complaint was the side effects of chemotherapy for cancer treatment (n = 84), that is, nausea, anorexia, dysethesia and so on. Other symptoms were dyspnea or shortness of breath (n = 49), pain originating from cancer (n = 38), pain originating from skeletal muscle (n = 38), anorexia (n = 25), and general fatigue (n = 18). Several symptoms were cough, edema, constipation or diarrhea, conscious disturbance, insomnia, paralysis, etc.
Of the chief complaints, 86.4%were closely connected with diseases or treatments for admission.
The mean number of patients who received acupuncture was 10.0/day. This was equal to about 20%of all patients (53beds) per day in our department.
[Conclusion]There were many patients whose chief complaints for acupuncture were closely connected with disease for admission. It is suggested that acupuncture treatment is accepted as one of treatments of internal medicine for inpatients in our department.

The activated clotting time (ACT) is used to assess adequacy of anticoagulation during cardiopulmonary bypass (CPB). However, ACT values during CPB do not correlate with heparin concentration and are affected by variations of such factors as hypothermia and hemodilution. ACT is also used to estimate protamine doses, because excess protamine may result in hypotension and an increase in bleeding after CPB. This study was designed to evaluate the effect of heparin and protamine administration that were administered based on whole blood heparin concentration using Hepcon/HMS (HC group) on the incidence of bleeding and blood transfusion after CPB. We treated 32 of adult cases and 36 pediatric cases. For the control group (NC group), an initial fixed dose of 300U/kg heparin was administered and if the ACT was less than 400s an additional fixed dose of 100U/kg heparin was administered. Heparin was neutralized with an initial fixed dose of protamine. For the HC group, the initial dose of heparin and the additional dose of heparin were based on an automated heparin dose response assay. The initial dose of protamine was based on the residual heparin concentration. The patients in the HC group received greater doses of heparin and lower doses of protamine than the patients in the NC group. In the pediatric HC group, the amount of TAT, FTC and D-dimer post CPB were smaller than those in the NC group. Operative time and closure time were similar the two groups. Operative bleeding, mediastinal chest tube drainage in the postoperative period were similar in the two groups. The volume of total blood transfusion was also comparable in the two groups. In conclusion, the monitoring of heparin concentration during CPB in children was effective for the maintenance of coagulation factors.

We report a 5-year-old girl with a diagnosis of an anomalous origin of the left coronary artery from the pulmonary artery with an intramural aortic route. The left coronary artery entered the aortic wall running parallel to the aorta. With the aid of cardiopulmonary bypass, she underwent establishment of two coronary artery systems by intraaortic reconstruction (unroofing and anastomosis). Her postoperative course was uneventful. Postoperative cineangiogram demonstrated patency and prograde flow in the new coronary systems.

We report a rare case of acute type A aortic dissection with paraplegia which was reversed using cerebrospinal fluid drainage (CFD). The patient was a 80-year-old man who was admitted with acute back pain and paraplegia. Computed tomographic scans showed an acute type A aortic dissection. Four hours after onset of paraplegia, CFD was initiated by inserting an intrathecal catheter at L3-L4. Cerebrospinal fluid was drained freely by gravity whenever the pressure exceeded 10cmH₂O. After 32h, the neurological deficit was completely resolved. CFD can be considered a useful treatment in patients with paraplegia after acute aortic dissection.

BACKGROUND/AIMS: The relationship between the appearance of an ulcer and postoperative bleeding after gastric endoscopic submucosal dissection (ESD) is not well understood. To explore this potential relationship, we retrospectively analyzed the short-term healing process of ESD. METHODS: A total of 520 consecutive lesions in 434 patients seen between January 2004 and December 2009 were retrospectively investigated. At the second-look endoscopy, which occurred between 1 and 8 days after ESD, artificial ulcers were categorized into 6 patterns according to Forrest's classification: spurting bleeding, oozing bleeding, non-bleeding visible vessel, adherent clot, black base/spot, and clean base. From these data, a short-term healing model of the artificial ulcer was generated. RESULTS: Ulcer base changed gradually from a bloody to a clean one. The bleeding or non-bleeding visible vessel categories, which occurred in approximately one quarter of the ulcers within 3 days of ESD, were rarely observed 4 days after ESD. CONCLUSIONS: Ulcers that occur after gastric ESD heal in line with a specific time course, and it appears that most healing occurs without massive bleeding.
Endoscopy ; Glycosaminoglycans ; Hemorrhage ; Humans ; Retrospective Studies ; Stomach Neoplasms ; Ulcer

A 72-year-old female with a colonic laterally spreading tumor (LST) was referred to our department. A total colonoscopy revealed a large nongranular LST, 30 mm in diameter, in the ascending colon. Detailed examination with chromoendoscopy confirmed that the lesion was an intramucosal tumor, and endoscopic submucosal dissection (ESD) was performed. After a circumferential incision around the lifted lesion with a submucosal fluid cushion, diffuse adipose tissue was observed in the submucosal layer beneath the lesion. The endoscopic view was blurred when dissecting the submucosal layer due to fat adhering to the lens. Since this made it difficult to continue the procedures, we infused water into the lumen and kept the endoscope tip immersed in the collected water. The resulting improved view made it possible to complete all procedures without withdrawing the endoscope to wipe the lens. The lesion was successfully resected en bloc without complications. The pathological examination indicated the curative resection of a tubulovillous adenoma. We propose that a submerged ESD could also be an effective procedure for colonic neoplasms with submucosal fat by avoiding blurring of the endoscopic view.
Adenoma ; Adipose Tissue ; Aged ; Colon ; Colon, Ascending ; Colonic Neoplasms ; Colonoscopy ; Endoscopes ; Female ; Humans ; Water

Endoscopic submucosal dissection (ESD) for early gastric cancer is a well-established procedure with the advantage of resection in an en bloc fashion, regardless of the size, shape, coexisting ulcer, and location of the lesion. However, gastric ESD is a more difficult and meticulous technique, and also requires a longer procedure time, than conventional endoscopic mucosal resection. These factors naturally increase the risk of various complications. The two most common complications accompanying gastric ESD are bleeding and perforation. These complications are known to occur both intraoperatively and postoperatively. However, there are other rare but serious complications related to gastric ESD, including aspiration pneumonia, stenosis, venous thromboembolism, and air embolism. Endoscopists should have sufficient knowledge about such complications and be prepared to deal with them appropriately, as successful management of complications is necessary for the successful completion of the entire ESD procedure.
Constriction, Pathologic ; Embolism, Air ; Hemorrhage ; Pneumonia, Aspiration ; Stomach Neoplasms ; Ulcer ; Venous Thromboembolism

A 53-year-old man was suspected of having an esophageal neoplasm. An endoscopic examination including Lugol chromoendoscopy suggested an esophageal squamous cell neoplasm limited to the lamina propria. A targeted biopsy showed atypical squamous cells, and an endoscopic submucosal dissection was performed 22 days after the previous endoscopy. Although a single 40 mm unstained area was observed by preoperative Lugol chromoendoscopy, intraoperative endoscopy revealed a 25 mm iodine-unstained area, with small unstained areas scattered on the oral side. We included the small unstained areas in the extent of the resection through assessment by preoperative endoscopy. Histopathologically, the tumor extent appeared to coincide with the preoperative assessment. Tumor cells were found in the basal-parabasal layers of the mucosa, in which small unstained areas were scattered, although the superficial layers exhibited well-differentiated cells containing glycogen in the cytoplasm. Although Lugol chromoendoscopy, which can induce chemical esophagitis, is widely used, re-epithelialization after mucosal damage by preoperative iodine staining may complicate the intraoperative demarcation of tumors.
Biopsy ; Cytoplasm ; Endoscopy ; Esophageal Neoplasms ; Esophagitis ; Glycogen ; Iodine ; Mucous Membrane ; Neoplasms, Squamous Cell ; Re-Epithelialization

BACKGROUND/AIMS: There have been several reports of thermal injury induced by argon plasma coagulation (APC) in animal models, but no follow-up studies have revealed the actual thermal injury. METHODS: APC was performed on the stomachs of two living minipigs with and without prior submucosal injection of normal saline. The power and argon gas flow were set to 60 watts and 2 L/min, respectively, and pulse durations of 5, 10, and 20 seconds were used. One of the minipigs was killed immediately thereafter and the other was killed 1 week later. RESULTS: The minipig killed immediately showed only subtle differences between noninjected and injected injuries under all the conditions, and the usefulness of prior submucosal injection was not obvious. However, the minipig killed 1 week later had a deep ulcer extending to the deeper muscle layer at the noninjected site where APC had been applied for 20 seconds, whereas tissue injury of the injected site was limited to the submucosal layer. CONCLUSIONS: Unexpected tissue damage can occur even using a short-duration APC. Prior submucosal injection for APC might be a safer alternative technique, especially in a thinner and narrower gut wall.
Argon ; Argon Plasma Coagulation ; Models, Animal ; Muscles ; Stomach ; Swine, Miniature ; Ulcer