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Kōbe-shi, Japan

A 73-year-old woman with Sjögren's syndrome and autoimmune neutropenia (AIN) associated with large granular lymphocytosis of the polyclonal T cell type, demonstrated autoimmune thrombocytopenia (AIT) at diagnosis of sigmoid colon cancer. Ten months later, both AIN and AIT had exacerbated to agranulocytosis and severe thrombocytopenia below 10×10(9)/L, respectively. There were no dysplastic features of bone marrow hematopoietic cells. Furthermore, an in vitro assay of hematopoietic progenitors showed normal granuloid and erythroid colony formation. Although we serially treated her with prednisolone (oral), filgrastim, intravenous high-dose immunoglobulin infusion, cyclophosphamide (oral), danazol, cyclosporine A (oral), and rituximab, number of neutrophils and platelets elevated only temporarily. During the course of agranulocytosis and severe thrombocytopenia, the patient also developed autoimmune hemolytic anemia (AIHA). She died of pneumonia 5 months after the onset of agranulocytosis. This case is very unique and novel in terms of autoimmune phenomena simultaneously directed to granulocytes, platelets, and red blood cells under the background of Sjögren's syndrome. Source

All neurologists have to make a differential diagnosis of consciousness loss by EEG. The judgment of epilepsy is especially important. Experts of neurology were also required to determine the level and etiology of the acute or chronic weakness or numbness by EMG with nerve conduction study. Hands on seminar and e-learning would be useful to acquire these tools. Source

Tomii K.,Kobe City Medical Center
Japanese Journal of Chest Diseases | Year: 2013

For more than 10 years, NPPV has been the first line treatment for acute exacerbation of COPD, cardiogenic pulmonary edema and acute respiratory failure in immunodeficient patients. Although the indications for other diseases such as pneumonia, asthma, ARDS, and interstitial pneumonia have not yet been established, many expert hospitals have been using NPPV for such diseases and reported some favorable data. For emergency departments, NPPV is suitable due to its easy application and can be used firstly for most acute respiratory failures before intubation. Actually, in our retrospective cohort study of emergent admission cases, the mortality of all acute respiratory failures decreased significantly after the introduction of NPPV as the first-line treatment. From the epidemiological data showing real world practices, NPPV is not used as much as we would expect from the guideline, and the large difference in the usage ratio between hospitals still exists. This issue is one of the greatest problems in acute care communities treating respiratory failures. Source

Yoshimura S.,Gifu University | Egashira Y.,Gifu University | Sakai N.,Kobe City Medical Center | Kuwayama N.,University of Toyama
Cerebrovascular Diseases | Year: 2011

Background: The purpose of this study was to clarify the clinical impact of endovascular treatment (EVT) on acute cerebral large vessel occlusion using a nationwide survey of Japan conducted in 2009. Methods: Patients admitted within 24 h after stroke onset were registered retrospectively. Treatment selection, methods, and clinical results were analyzed. Results: A total of 1,963 patients (855 women, 1,108 men) treated in 2008 were registered from 68 medical centers in Japan. Mean age on admission was 74.1 ± 12.2 years (range 7-100 years). The first treatment was conservative therapy in 68%, intravenous tissue plasminogen activator (IV-tPA) in 21%, EVT in 9%, and combined IV-tPA + EVT in 2%. EVT mainly comprised angioplasty, intra-arterial thrombolysis and/or the combination of both. Patients treated ≤3 h after onset (1,286 cases) showed better clinical outcomes with combined IV-tPA + EVT than with conservative therapy, and significant differences in outcomes were seen for patients with occlusion of the basilar artery (p < 0.01) or middle cerebral artery (p < 0.01), but not the internal carotid artery. At >3 h after onset (677 patients), no IV-tPA was performed, and EVT was performed in 11%. Among the patients treated by EVT, there were significant differences in clinical outcome between complete recanalization (TIMI grade 3) and partial/no recanalization (TIMI grade 0-2) (p < 0.001; OR 5.98; 95% CI 3.27-10.96) and between any recanalization (TIMI grade 1-3) and no recanalization (TIMI grade 0) (p < 0.001; OR 36.15; 95% CI 4.88-267.53). Conclusions: This nationwide survey showed the efficacy of EVT with IV-tPA in patients with occlusion of the basilar or middle cerebral artery, but not of the internal casrotid artery. The effects of new endovascular devices should be clarified in the near future. Copyright © 2011 S. Karger AG, Basel. Source

Noninvasive positive pressure ventilation (NPPV) is often used for patients in terminal states, those with do-not-intubate orders, malignancy, the elderly, and those who have some limitations for life-sustaining procedures. However, the effectiveness of NPPV in such patients is only clear for diseases in which NPPV is clearly recommended for patients without treatment limitations, such as chronic obstructive pulmonary disease or cardiogenic pulmonary edema. In other diseases or after the initial NPPV trial has failed, we need to fully discuss where to set the goals of NPPV with patients and family, and then we should decide whether to continue or not If the goal of NPPV is to relieve dyspnea, we should discontinue NPPV when patients experience discomfort due to NPPV or lose consciousness. It is reasonable to consider increasing opioids or applying a high flow nasal cannula, which is more comfortable for patients than NPPV. Source

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