Differenting Cushing’s disease from myasthenia gravis : A case report

The patient is a 77-year-old woman with a history of diabetes mellitus that was refractory to the medication and dietary restrictions. Four months prior to the admission, she developed a dropped head and ptosis that worsened in the evening. These symptoms were improved by the edrophonium test and the 3 Hz repetitive nerve stimulation testing was positive ; nevertheless, anti-acetylcholine and anti-muscle-specific tyrosine kinase antibodies were negative. Further examination demonstrated sustained hypokalemia and high levels of cortisol and ACTH. Moreover, CRH and high-dose dexamethasone suppression testings were positive and MRI demonstrated pituitary microadenoma. Based on these findings, she was subsequently diagnosed with Cushing’s disease. After the resection of the pituitary tumor, ptosis improved with an alleviation of systemic edema, suggesting that it was caused by an eyelid edema. This case uniquely illustrates that Cushing’s disease may mimic myasthenia gravis. Differentiation of the two disorders is crucial as treatment with steroids could compromise the interpretation of diagnostic testings for Cushing’s disease and might result in a disease exacerbation. In this case, the history of treatment-refractory diabetes mellitus was helpful cue to differentiate the two disorders

Differences in treatment and survival between elderly patients with thoracic esophageal cancer in metropolitan areas and other areas

To address the major issue of regional disparity in the treatment for elderly cancer patients in an aging society, we compared the treatment strategies used for elderly patients with thoracic esophageal cancer and their survival outcomes in metropolitan areas and other regions. Using the national database of hospital-based cancer registries in 2008-2011, patients aged 75 years or older who had been diagnosed with thoracic esophageal cancer were enrolled. We divided the patients into two groups: those treated in metropolitan areas (Tokyo, Kanagawa, Osaka, Aichi, Saitama, and Chiba prefectures) with populations of 6 million or more and those treated in other areas (the other 41 prefectures). Compared were patient backgrounds, treatment strategies, and survival curves at each cancer stage. In total, 1236 (24%) patients from metropolitan areas and 3830 (76%) patients from nonmetropolitan areas were enrolled. Patients in metropolitan areas were treated at more advanced stages. There was also a difference in treatment strategy. The 3-year survival rate among cStage I patients was better in metropolitan areas (71.6% vs. 63.7%), and this finding mainly reflected the survival difference between patients treated with radiotherapy alone. For cStage II-IV patients, there were no differences. Multivariable Cox proportional hazard analysis including interaction terms between treatment areas, cStage, and the first-line treatments revealed that treatments in the metropolitan areas were significantly associated with better survival among patients treated with radiotherapy alone for cStage I cancer. Treatment strategies for elderly patients with thoracic esophageal cancer and its survival outcomes differed between metropolitan areas and other regions

Lower local recurrence rate after robot-assisted thoracoscopic esophagectomy than conventional thoracoscopic surgery for esophageal cancer

The oncological advantages of robot-assisted thoracoscopic esophagectomy (RATE) over conventional thoracoscopic esophagectomy (TE) for thoracic esophageal cancer have yet to be verified. In this study, we retrospectively analyzed clinical data to compare the incidences of recurrence within the surgical field after RATE and TE as an indicator of local oncological control. Among 121 consecutive patients with thoracic esophageal or esophagogastric junction cancers for which thoracoscopic surgery was indicated, 51 were treated with RATE while 70 received TE. The number of lymph nodes dissected from the mediastinum, duration of the thoracic portion of the surgery, and morbidity due to postoperative complications did not differ between the two groups. However, the rate of overall local recurrence within the surgical field was significantly (P=0.039) higher in the TE (9%) than the RATE (0%) group. Lymph node recurrence within the surgical field occurred in left recurrent nerve, left tracheobronchial, left main bronchus and thoracic paraaortic lymph nodes, which were all difficult to approach to dissect. The other two local failures occurred around the anastomotic site. This study indicates that using RATE enabled the incidence of recurrence within the surgical field to be reduced, though there were some limitations

Surgical Outcomes of Posterior Short Segment Fixation for Thoracolumbar Burst Fractures: A Study of Patients Treated without Vertebroplasty

There is no widespread agreement regarding the treatment of thoracolumbar burst fractures. While performing posterior short segment fixation of thoracolumbar burst fractures, we evaluated therapeutic outcomes in patients treated with screw insertion into fractured vertebral bodies without vertebroplasty. We also investigated the limitations associated with the treatment of burst fractures when vertebroplasty is not performed. Twenty-one of 51 patients with thoracolumbar burst fractures who were treated surgically in Ohta Nishinouchi Hospital were evaluated in the present study. These patients underwent posterior short segment fixation with screw insertion into the fractured vertebral bodies (only pedicle screws were inserted one level above and one level below the fractured vertebral bodies) without vertebroplasty. Vertebral angles were measured before surgery, immediately after surgery, and at the final follow-up examination. Changes in vertebral angles were compared and analyzed. The mean vertebral angles before and after surgery and at the final follow-up examination were 15.4°, 6.6°, and 9.1°, respectively. The mean postoperative correction loss was 2.5°. The therapeutic outcomes of posterior short segment fixation with screw insertion into fractured vertebral bodies without vertebroplasty were generally favorable

Peritumoral CD16b positive-neutrophil accumulation strongly correlates with regional lymph node metastasis in thoracic esophageal squamous cell cancer

BackgroundThe mechanism underlying cancer cell metastasis from the tumor to regional lymph nodes is not yet fully understood. We hypothesized that peritumoral neutrophil accumulation promotes regional lymph node metastasis in thoracic esophageal squamous cell cancer.MethodsBetween 2010 and 2019, 126 thoracic esophageal squamous cell cancer patients received curative (R0) esophagectomy without preoperative treatment in our hospital. Using paraffin-embedded resected tumors, we performed immunohistochemical analysis of CD16b-positive neutrophil accumulation in the peritumoral area, which was defined as a 1-mm region centered on the border separating the malignant cell nests from the host tissue. The relationship between the density of peritumoral CD16b staining and pathological lymph node metastasis or 5-year overall survival was evaluated.ResultsAlthough the clinicopathological characteristics of CD16b-high and CD16b-low patients did not differ, greater pathological lymph node metastasis (P 25 (P < .001). On the other hand, blood neutrophil counts did not correlate with lymph node metastasis

A family with type A insulin resistance syndrome caused by a novel insulin receptor mutation

Summary:A 17-year-old boy was referred to our endocrinology clinic for a clinical investigation of hyperinsulinemia. An oral glucose tolerance test showed plasma glucose concentrations in the normal range. However, insulin concentrations were considerably elevated (0 min: 71 μU/mL; 60 min: 953 μU/mL), suggesting severe insulin resistance. An insulin tolerance test confirmed that he had insulin resistance. There was no apparent hormonal or metabolic cause, including obesity. The patient had no outward features of hyperinsulinemia, including acanthosis nigricans or hirsutism. However, his mother and grandfather also had hyperinsulinemia. Genetic testing showed that the patient (proband), his mother, and his grandfather had a novel p.Val1086del heterozygous mutation in exon 17 of the insulin receptor gene (INSR). Although all three family members have the same mutation, their clinical courses have been different. The onset of the mother\u27s diabetes was estimated at 50 years, whereas the grandfather developed diabetes at 77 years.Learning points:Type A insulin resistance syndrome is caused by mutations in the insulin receptor (INSR) gene and results in severe insulin resistance. Genetic evaluation should be considered in adolescents or young adults with dysglycemia when an atypical phenotype, such as severe insulin resistance, or a relevant family history is observed. Clinical courses may differ even if the same genetic mutation is found in a family

THE FUKUSHIMA DISASTER – SYSTEMIC FAILURES AS THE LACK OF RESILIENCE

This paper looks at the Fukushima disaster from the perspective of resilience engineering, which replaces a search for causes with an understanding of how the system failed in its performance. Referring to the four resilience abilities of responding, monitoring, learning, and anticipating, the paper focuses on how inadequate engineering anticipation or risk assessment during the design, in combination with inadequate response capabilities, precipitated the disaster. One lesson is that systems such as nuclear power plants are complicated, not only in how they function during everyday or exceptional conditions, but also during their whole life cycle. System functions are intrinsically coupled synchronically and diachronically in ways that may affect the ability to respond to extreme conditions

A New Composite Structure of PEDOT/PSS: Macro-Separated Layers by a Polyelectrolyte Brush

Polyethylene dioxythiophene and polyethylene sulfonic acid (PEDOT/PSS) composite is gathering attention as an organic transparent conductive film material. However, it requires a core-shell structure in which conductive PEDOT is covered with insulating PSS. Providing film formability and a carrier to PEDOT, the PSS shell hinders carrier conduction as an insulating barrier. In this study, we realized that creating a macro-separated PEDOT/PSS composite by using a polyelectrolyte brush substrate and in-situ PEDOT polymerization without the PSS barrier increases durability and conductivity in comparison with commercially available PEDOT/PSS film, achieving a conductivity of 5000&ndash;6000 S/cm