A case of abdominal aortic aneurysm presenting as symptomatic disseminated intravascular coagulation treated with endovascular aneurysm repair and postoperative administration of Nafamostat mesylate

BACKGROUND

Cases of abdominal aortic aneurysm discovered as purpura on the extremities with disseminated intravascular coagulation (DIC) are rare. The number of currently established strategies for the control of DIC with aortic aneurysm is limited.

CASE PRESENTATION

An 85-year-old woman was referred to the hematology department because of purpura on her shoulder and thigh. Enhanced fibrinolytic-type DIC was diagnosed by a blood test. Enhanced computed tomography (CT) revealed 60-mm abdominal aortic and 42-mm right common iliac aneurysms. We performed endovascular aneurysm repair (EVAR) and coiling of the right internal iliac artery with postoperative administration of Nafamostat mesylate. The patient promptly recovered from DIC, and the purpura gradually disappeared.

CONCLUSIONS

We safely performed EVAR with postoperative administration of Nafamostat mesylate for an abdominal aortic aneurysms that presented as symptomatic DIC.

Pure Red Cell Aplasia and Chromosomal Abnormality in a Patient With Lung Adenocarcinoma Receiving Immune Checkpoint Inhibitors: A Case Report

BACKGROUND/AIM

Immune checkpoint inhibitors can induce immune-related adverse events in various organs, thus careful observation is required.

CASE REPORT

A 69-year-old man was diagnosed with advanced lung adenocarcinoma and treated with combined therapy of carboplatin plus pemetrexed plus pembrolizumab. After two cycles of treatment, anemia was noted. Myelosuppression due to cytotoxic anticancer agents was suspected and the cytotoxic agents were discontinued, followed by three courses of pembrolizumab monotherapy. However, the anemia persisted, requiring red blood cell transfusions. A bone marrow biopsy revealed erythroblast hypoplasia and chromosomal abnormalities, resulting in a diagnosis of pure red cell aplasia. These adverse events were considered immune-related because of the treatment history with an immune checkpoint inhibitor, and 60 mg/day (1 mg/kg/day) of prednisolone was initiated. Anemia improved, and it did not recur during the tapering of prednisolone.

CONCLUSION

Immune-related pure red cell aplasia should be considered for patients presenting anemia during treatment with immune checkpoint inhibitors.

Glucocorticoid treatment and clinical outcomes in patients with polymyalgia rheumatica: A cohort study using routinely collected health data

OBJECTIVE

We aimed to describe the following in patients with polymyalgia rheumatica (PMR): (1) real-world glucocorticoid (GC) therapy, (2) improvement in inflammatory parameters associated with disease activity (C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]), and (3) incidence of GC-related adverse events (AEs).

METHODS

A cohort study was conducted using a Japanese electronic medical records database. We included newly diagnosed PMR patients aged≥50years with baseline CRP levels≥10mg/L and/or ESR>30mm/h and an initial GC dose of≥5mg/day. The outcomes were GC dose, inflammatory parameters, and GC-related AEs.

RESULTS

A total of 373 PMR patients (mean age, 77.3 years) were analyzed. The median initial GC dose was 15.0mg/day, which gradually decreased to 3.5mg/day by week 52. The median cumulative GC dose at week 52 was 2455.0mg. The median CRP level on day 0 was 64.3mg/L, which decreased during weeks 4-52 (1.4-3.2mg/L). At week 52, 39.0% of patients had a CRP level>3.0mg/L. The cumulative incidence of GC-related AEs at week 52 was 49.0% for osteoporosis, 30.2% for diabetes, 14.9% for hypertension, 12.2% for peptic ulcer, 11.3% for dyslipidemia, 2.9% for glaucoma, and 4.3% for serious infection. The incidence of osteoporosis and diabetes increased with the GC dose.

CONCLUSION

The incidence of GC-related AEs was associated with the GC dose in PMR patients. Further research is required to identify treatment strategies that can effectively control PMR disease activity while minimizing GC use.

Skeletal Muscle Mass Index Reduction Rate as a Prognostic Indicator for Patients Undergoing Pancreatectomy for Pancreatic Cancer

Background/Aim

There have been many studies on skeletal muscle depletion before surgery, and skeletal muscle depletion is a known risk factor for poor prognosis. However, reports on the association between changes in skeletal muscle mass and prognosis after surgery for pancreatic cancer are very few.

Patients and Methods

The data of 137 patients who underwent pancreatectomy for pancreatic cancer between 2005 and 2022 were reviewed. Muscle areas were measured at the third lumbar vertebral level, and skeletal muscle mass index (SMI) reduction rates were calculated. Patients were divided into two groups using receiver operating characteristic (ROC) curve analysis based on the SMI reduction rate with a cutoff of 14% reduction rate. The clinicopathological factors, overall survival (OS), and recurrence-free survival (RFS) were compared between the two groups. Survival rates were analyzed both univariately and multivariately to clarify the factors associated with poor prognosis after pancreatectomy.

Results

A total of 102 patients met the inclusion criteria. SMI reduction rate ≥14% significantly correlated with advanced age and higher incidence of postoperative complications. In the multivariate Cox regression analysis, preoperative prognostic nutritional index (PNI) <40 and SMI reduction rate ≥14% were significantly associated with poor OS. Tumor size ≥3.0 cm, preoperative neutrophile-lymphocyte ratio ≥3.0, and SMI reduction rate ≥14% were significantly associated with poor RFS.

Conclusion

The rate of skeletal muscle mass reduction after pancreatic surgery is an independent prognostic factor for survival in patients with pancreatic cancer.

Transcriptome analysis of an AKT inhibitor-resistant endometrial cancer cell line

BACKGROUND

Drug resistance in endometrial cancer (EC) is a serious problem and a barrier to improving prognosis. The PI3K/AKT/mTOR pathway is highly activated in EC and can serve as a potential therapeutic target. Inhibitors against AKT have been developed, but resistance to these inhibitors is a concern. This study aimed to establish AKT inhibitor resistant cell lines and identify differentially expressed genes (DEGs) between parental and AKT inhibitor resistant cell lines to understand the mechanism of drug resistance to AKT inhibitors in EC.

METHODS

The sensitivity of eight EC cell lines to AKT inhibitor was analyzed. One of them was used to establish a drug-resistant cell line. DEGs were examined using RNA sequencing (RNA-seq). Furthermore, DEGs were comprehensively analyzed to identify hub genes. Hub genes were evaluated using quantitative real-time polymerase chain reaction.

RESULTS

RNA-seq identified 617 DEGs. Hub genes were selected using bioinformatics analysis. The top 10 hub genes were TNF, CDH1, CCND1, COL1A1, CDH2, ICAM1, CAV1, THBS1, NCAM1, and CDKN2A. Relative mRNA expression was significantly upregulated for TNF, CDH1, CCND1, THBS1, p16INK4a, and p14ARF and significantly downregulated for CDH2, ICAM1, and NCAM1 in borussertib-resistant EC cell line.

CONCLUSIONS

Drug resistance to AKT inhibitors may depend on genes related to cell adhesion-mediated resistance and transforming growth factor β signaling.

A case of difficult-to-diagnose hepatic reactive lymphoid hyperplasia finally diagnosed by using PCR analysis of IgH-gene rearrangements: a case report

Reactive lymphoid hyperplasia (RLH) of the liver is extremely rare. Despite advancements in diagnostic imaging technology, it is still difficult to distinguish from hepatocellular carcinoma (HCC). Herein, we present a case of hepatic RLH mimicking HCC that was postoperatively diagnosed using several imaging modalities. A 78-year-old female was referred to our hospital with a positive hepatitis C virus antibody (HCV Ab) test. Ultrasonography revealed a 13 mm isoechoic lesion in segment 8 of the liver. Contrast-enhanced computed tomography (CE-CT) demonstrated arterial hyperintensity and washout during the later phase. On ethoxybenzyl magnetic resonance imaging (EOB-MRI), the lesion was hyperenhanced in the arterial phase and of low intensity in the hepatocyte phase. Although the tumor markers were all within normal limits, the pattern of contrast enhancement of the tumor on CT and MRI was consistent with that of HCC. We performed S8 segmentectomy of the liver. Histological examination of the resected specimen revealed dense lymphoid tissue of variable sizes and shapes with expanded germinal centers. Immunohistochemical examination was positive for CD3, CD10 (germinal center), and CD20, and negative for B-cell lymphoma 2 (bcl-2) (germinal center) and Epstein-Barr virus (EBV). A polymerase chain reaction (PCR) analysis of IgH-gene rearrangements revealed polyclonality. Based on these findings, hepatic RLH was diagnosed. The postoperative course was uneventful, and the patient was discharged on the 10th postoperative day. She had a good quality of life after surgery and no liver nodule recurrence was detected at the 4-month medical follow-up. Hepatic RLH is an extremely rare disease and preoperative diagnosis is difficult. This should be considered in the differential diagnosis of single small hepatic tumors. An echo-guided biopsy and careful observation of imaging may help diagnose hepatic RLH, and a PCR analysis of IgH-gene rearrangements would be necessary for the definitive diagnosis of hepatic RLH.

Clinical features of polymyalgia rheumatica patients in Japan: Analysis of real-world data from 2015 to 2020

OBJECTIVES

To assess clinical features in patients with polymyalgia rheumatica (PMR) in Japan by the International Classification of Disease (ICD)-10 code assignment.

METHODS

Demographics, treatment patterns, and concomitant diseases (identified using ICD-10 code only) in patients who were assigned the PMR ICD-10 code M35.3 at least once between 1 January 2015 and 31 December 2020 were aggregated from a nationwide medical information database owned by the Health, Clinic, and Education Information Evaluation Institute.

RESULTS

The cumulative number of patients with PMR was 6325 (mean [standard deviation] age, 74.3 [11.4] years; male:female, 1:1.3). Most patients were >50 years (96.5%) with >33% between 70 and 79 years. Glucocorticoids were prescribed in ∼54% of patients within 30 days of PMR code assignment. All other drug types were prescribed in <5% of patients. Hypertension, diabetes mellitus, rheumatoid arthritis, and osteoporosis were noted in >25% and giant cell arteritis in 1% of patients. During the study period, 4075 patients were newly assigned the PMR code and 62% were prescribed glucocorticoids within 30 days.

CONCLUSIONS

This is the first retrospective real-world data analysis describing the clinical features of PMR in a large patient population from Japan. Further studies of prevalence, incidence, and clinical features are warranted in patients with PMR.

Association between Toe Pressure Strength in the Standing Position and Maximum Walking Speed in Older Adults

BACKGROUND

Considering concerns about conventional toe grip strength, we devised a method to measure toe pressure strength in the standing position, which is close to the actual motion. This study examined the association between toe pressure strength in the standing position and walking speed among older adults.

METHODS

This cross-sectional study included 150 community-dwelling older adults (81±8 years, 73% female) who participated in the physical fitness test. We analyzed the correlation between the participants' maximum walking speed and physical function. Furthermore, we performed regression analysis with the maximum walking speed as the dependent variable to examine the association with toe pressure strength in the standing position. We also examined the association between maximum walking speed and toe pressure strength in the standing position by introducing a covariate.

RESULTS

Correlation analysis revealed a significant positive correlation between maximum walking speed and toe pressure strength in the standing position, with a moderate effect size (r=0.48, p<0.001). Moreover, multiple regression analysis with covariates showed an association between maximum walking speed and toe pressure strength in the standing position (standardization factor=0.13, p<0.026).

CONCLUSION

Toe pressure strength in the standing position was associated with maximum walking speed. This finding clarifies the significance of assessing toe pressure strength in the standing position and suggests that enhanced toe pressure strength in the standing position may increase maximum walking speed.

Diagnostic Immunocytostaining with Peroxisome Proliferator-Activated Receptor-Gamma in Urine Cytology Samples

INTRODUCTION

Urine cytology is a common method for detection of urothelial carcinoma (UC), however, is not high sensitivity. Improvement of the accuracy of cytodiagnosis using immunocytostaining as an auxiliary method is needed. This study aimed to determine the cytodiagnostic usefulness of peroxisome proliferator-activated receptor-gamma (PPAR-γ) immunocytostaining in urine cytology for the detection of UCs, particularly low-grade urothelial carcinomas (LGUC).

METHODS

PPAR-γ immunocytostaining was performed for 37 UC cases and 26 benign cases. Among the UC cases, 22 cases were of the papillary proliferation type, not including the mixed type comprising both papillary and flat growth. Fifteen LGUC cases of all papillary proliferation types were included. For comparison, the same samples were also immunocytostained for p53 and Ki-67.

RESULTS

Of the UC cases, 25 of 37 were positive for PPAR-γ, while 24 of the 26 benign cases were PPAR-γ-negative. Regardless of histological grading, 13 of the 22 UC cases with papillary proliferation were PPAR-γ-positive. In particular, PPAR-γ immunocytostaining showed higher sensitivity for LGUC cases than that of the other biomarkers. Regarding LGUC specifically, 4 of 10 cases not identified by primary cytology were detected by PPAR-γ immunocytostaining.

CONCLUSION

PPAR-γ immunocytostaining enhances the accuracy of urine cytodiagnosis. Furthermore, PPAR-γ is a more useful immunobiomarker in urine cytology than p53 and Ki-67, the commonly used immunobiomarkers for malignant cell detection.

A Rare Case of Dissecting Superior Mesenteric Artery Aneurysm in Granulomatosis with Polyangiitis

An asymptomatic dissecting superior mesenteric artery (SMA) aneurysm in granulomatosis with polyangiitis (GPA), historically termed Wegener's granulomatosis, is rare. We herein describe a 68-year-old man who was diagnosed with GPA based on a high level of proteinase 3 (PR3)-antineutrophil cytoplasmic antibody (ANCA). One year after remission of GPA, the patient developed pyelonephritis, and his PR3-ANCA level increased again. Computed tomography showed a rapid increase in the size of the dissecting SMA aneurysm. The patient underwent successful endovascular stent-graft repair. At the time of this writing, 3 years had passed since the surgery and the clinical course was good.

Differences in Improvement of Physical Function in Older Adults with Long-Term Care Insurance with and without Falls: A Retrospective Cohort Study

(1) Background: This study examined the differences in changes in physical function with and without falls after daycare use among frail older adults with long-term care insurance (LTCI). (2) Methods: In this retrospective cohort study, 82 of 96 consecutive daycare center users met the inclusion criteria. The participants were divided into two groups based on the presence or absence of falls 6-12 months after use. Participant characteristics in the fall and non-fall groups and physical function at baseline and six months in each group were compared. Using analysis of covariance, we analyzed physical function and its changes between the two groups, and cut-off values were calculated using receiver operating characteristic curves. (3) Results: Gait speed, timed up-and-go test, and 30 s chair stand test (CS30) improved significantly over six months in the no-fall group (n = 70) and all participants (n = 82) (p < 0.01). Gait speed in the fall group (n = 12) improved significantly over six months (p = 0.04). The fall group had significantly lower adjusted ΔCS30 scores than the no-fall group (p = 0.03), with a cutoff value of 2 (p = 0.024). (4) Conclusions: In older adults with LTCI, physical function with and without falls after daycare use differed by ΔCS30, with a cutoff value of 2.

Heterologous expression and characterization of salt-tolerant β-glucosidase from xerophilic Aspergillus chevalieri for hydrolysis of marine biomass

A salt-tolerant exo-β-1,3-glucosidase (BGL_MK86) was cloned from the xerophilic mold Aspergillus chevalieri MK86 and heterologously expressed in A. oryzae. Phylogenetic analysis suggests that BGL_MK86 belongs to glycoside hydrolase family 5 (aryl-phospho-β-D-glucosidase, BglC), and exhibits D-glucose tolerance. Recombinant BGL_MK86 (rBGL_MK86) exhibited 100-fold higher expression than native BGL_MK86. rBGL_MK86 was active over a wide range of NaCl concentrations [0%-18% (w/v)] and showed increased substrate affinity for p-nitrophenyl-β-D-glucopyranoside (pNPBG) and turnover number (kcat) in the presence of NaCl. The enzyme was stable over a broad pH range (5.5-9.5). The optimum reaction pH and temperature for hydrolysis of pNPBG were 5.5 and 45 °C, respectively. rBGL_MK86 acted on the β-1,3-linked glucose dimer laminaribiose, but not β-1,4-linked or β-1,6-linked glucose dimers (cellobiose or gentiobiose). It showed tenfold higher activity toward laminarin (a linear polymer of β-1,3 glucan) from Laminaria digitata than laminarin (β-1,3/β-1,6 glucan) from Eisenia bicyclis, likely due to its inability to act on β-1,6-linked glucose residues. The β-glucosidase retained hydrolytic activity toward crude laminarin preparations from marine biomass in moderately high salt concentrations. These properties indicate wide potential applications of this enzyme in saccharification of salt-bearing marine biomass.

First-onset type 1 diabetes in an elderly woman with multiple islet-associated autoantibodies, and a literature review

An 80-year-old Japanese woman had shown no indication of diabetes but regularly saw a primary-care physician for health management. Six months before her referral to our hospital, her HbA1c was 6.0%. She was referred to us for diabetic ketosis because she was urine ketone body-positive with a blood glucose level of 397 mg/dL and HbA1c of 14.6%. She was diagnosed with type 1 diabetes mellitus (T1DM) with glutamic acid decarboxylase (GAD) antibodies >2,000 U/mL (by ELISA) and IA-2 antibodies >30 U/mL. Insulin injections were introduced, and she was discharged. Laboratory tests during her hospitalization were negative for thyroid antibodies (TgAb, TPOAb). Elderly individuals with first-onset T1DM who are positive for IA-2 antibody are rare, and multiple-positive cases of pancreatic islet-associated autoantibodies are particularly rare. IA-2 antibodies have an approx. 60% positive rate in acute-onset T1DM, but they are more likely to be positive in children and adolescents and are known to turn negative earlier than anti-GAD antibodies. Although a large amount of insulin is needed in general in such cases, our patient was successfully treated with a small amount of insulin. IA-2 antibody has been reported to be positive even in GAD antibody-negative individuals. In some cases, IA-2 antibody and other antibodies are positive even in elderly-onset diabetes, and this contributes to the diagnosis of T1DM.

The significance of information and communication technology education via tablets in college of physical therapy

[Purpose] This study aimed to clarify whether collaborative learning could be promoted via information and communication technology education using tablets at college of physical therapy. [Participants and Methods] An online survey was conducted to evaluate collaborative learning among 81 first-year students at the Department of Physical Therapy actively using tablets in classes (six specific categories). [Results] The Friedman test had significant results, and a significant primary effect was observed between each questionnaire item. Following this, the Bonferroni test was performed for multiple comparisons, with significant differences were observed among certain items. [Conclusion] We reported employing tablets in the classroom positively impacted collaborative learning. Here, among the evaluations of collaborative learning, the items with the best results corresponded mainly to communication activation between students.

Improvement in salt-tolerance of Aspergillus oryzae γ-glutamyl transpeptidase via protein chimerization with Aspergillus sydowii homolog

γ-Glutamyl transpeptidase is one of the key enzymes involved in glutamate production during high-salt fermentation of soy sauce and miso by koji mold, Aspergillus oryzae. However, the activity of γ-glutamyl transpeptidase from A. oryzae (AOggtA) is markedly reduced in the presence of NaCl, thus classifying it as a non-salt-tolerant enzyme. In contrast, the homologous protein from the xerophilic mold, A. sydowii (ASggtA) maintains its activity under high-salt conditions. Therefore, in this study, a chimeric enzyme, ASAOggtA, was designed and engineered to improve salt-tolerance in AOggtA by swapping the N-terminal region, based on sequence and structure comparisons between salt-tolerant ASggtA and non-salt-tolerant AOggtA. The parental AOggtA and ASggtA and their chimera, ASAOggtA, were heterologously expressed in A. oryzae and purified. The chimeric enzyme inherited the superior activity and stability from each of the two parent enzymes. ASAOggtA showed > 2-fold greater tolerance than AOggtA in the presence of 18% NaCl. In addition, the chimera showed a broader range of pH stability and greater thermostability than ASggtA. AOggtA and ASAOggtA were sy over the range pH 3.0 to pH 10.5. Thermal stability was found to be in the order AOggtA (57.5 °C, t_1/2 = 32.5 min) > ASAOggtA (55 °C, t_1/2 = 20.5 min) > ASggtA (50 °C, t_1/2 = 12.5 min). The catalytic and structural characteristics indicated that non-salt-tolerant AOggtA would not undergo irreversible structural changes in the presence of NaCl, but rather a temporary conformational change, which might result in reducing the substrate binding and catalytic activity, on the basis of kinetic properties. In addition, the chimeric enzyme showed hydrolytic activity toward L-glutamine that was as high as that of AOggtA. The newly-designed chimeric ASAOggtA might have potential applications in high-salt fermentation, such as miso and shoyu, to increase the content of the umami-flavor amino acid, L-glutamate.

Comparison of toe pressure strength in the standing position and toe grip strength in association with the presence of assistance in standing up: a cross-sectional study in community-dwelling older adults

PURPOSE

We believe that toe pressure strength in the standing position, which is closer to the actual movement, is more associated with standing up in the older adults than the conventional toe grip strength. Therefore, the purpose of this study is to examine the association between toe pressure strength in the standing position and the presence of assistance in standing up in the older adults.

METHODS

Ninety-five community-dwelling older adults (82 ± 8 years old, 72% female) were included in this study. The patients were evaluated based on their need for assistance in standing up. Physical functions, including toe pressure strength in the standing position, toe grip strength, hand grip strength, knee extension strength, one-leg standing time with eyes open, and maximal walking speed, were measured.

RESULTS

When compared with and without assistance to stand up, the group requiring assistance had weaker toe pressure strength in the standing position than the group without assistance (p = 0.015, ES = 0.53). After adjusting for confounding factors, the final model revealed that toe pressure strength in the standing position was associated with the use of assistance in standing up (odds ratio 0.94 [0.88-0.99, p = 0.025]).

CONCLUSION

Toe pressure strength in the standing position was associated with the use of assistance in standing up in older adults. Improving toe pressure strength in the standing position may facilitate the ability of older adults to stand up.

The inclusion of nuclear area improves the Paris system for reporting urinary cytology

OBJECTIVE

The Paris System for Reporting Urinary Cytology (TPS) is a well-known urinary diagnostic model; however, occasional false-positives are a problem. To address this issue, we developed an improved algorithm (IA), based on additional cytological features, for TPS diagnosis.

METHODS

Cytological features were evaluated in 29 hard-to-classify cases, including 22 malignant cases and seven benign cases, using image analysis. The optimal IA was determined using the area under the receiver operating characteristic curve as an index. Re-evaluation was performed by applying measured values to the TPS and IA algorithms.

RESULTS

Using TPS, 12 of the 22 malignant cases were reassigned to a more appropriate category, and the remaining 10 malignant cases remained hard-to-classify. Two of the seven benign cases were classified as suspicious for high-grade urothelial carcinoma, and the remaining five benign cases remained in the original category. The IA, which included nuclear area as a parameter, showed the same diagnostic sensitivity as TPS, and three of the seven benign cases were reassessed as negative. Thus, the positive and negative predictive values of the IA were higher than those of TPS (84.6% and 100% vs 75.9% and 0%).

CONCLUSIONS

The newly developed IA is a practical algorithm with which to address the limitations of TPS and thus may contribute to improved diagnostic accuracy.

A ruptured sarcomatoid hepatocellular carcinoma treated with combined immunotherapy

Sarcomatoid hepatocellular carcinoma (sHCC) is a rare phenotype of HCC with extremely poor prognosis and no established pharmacological treatment. Interventional therapies such as radiofrequency ablation (RFA) or transcatheter arterial embolization (TAE) have been shown to limit the development of sHCC through mechanisms involving hypoxia-induced epithelial-mesenchymal transition. This report describes an 83-year-old man who developed sHCC 2 years after RFA treatment for HCC and experienced sHCC rupture. Following TAE-induced hematostasis, he was administered lenvatinib for tumor control. Although his physical status had improved, due to loss of fever and attenuation of arterial enhancement in the tumor, for 1 month after lenvatinib administration, tumor re-growth was observed 2 months after lenvatinib treatment. His general condition was preserved, and he was treated with 10 courses of atezolizumab plus bevacizumab (Atez+Bev), resulting in tumor shrinkage that was maintained for 3-8 months after Atez+Bev. Findings in this patient showed that combined immunotherapy was effective for sHCC. Further investigation in additional patients is required to maximize prognosis in patients with sHCC.

The relationship between children's somatotypes, motor examination results, and motor skills: assessing 6- to 10-year-olds

[Purpose] Childhood motor disorders and obesity are major health problems and concerns in children today. We performed a physical examination to test the motor system and motor ability of elementary school children based on their body types. [Participants and Methods] The obesity levels of 161 elementary school students aged six to ten were calculated based on the gender, age, and standard weight for each height category to classify them into somatotype groups, and analyze the relationships among the results of four motor examination items, Physical Fitness Test, and body composition analysis for two groups. [Results] More obese children were unable to reach the floor while performing a standing forward bend compared to non-obese children. In addition, a significant difference was found in the assessment of motor performance while performing side-to-side jumping, and obese children showed better values. Many endomorphic children were also unable to touch the floor with their hands when performing the standing forward bend. Among the items from a physical fitness test, the side-to-side hops revealed significant differences. There were no somatotype-related differences in the results of the body composition analysis. [Conclusion] In children aged six to ten years, somatotype differences were not associated with motor skill or body composition.

Cystic Adventitial Disease of the Popliteal Artery With Recurrent Intermittent Claudication After Drug-Coating Balloon Angioplasty: A Case Report Treated by Surgical Treatment

Cystic adventitial disease of the popliteal artery is a rare cause of unilateral intermittent claudication. The etiology of cystic adventitial disease is unknown, and affected patients are younger than those diagnosed with chronic arteriosclerosis. A 62-year-old man presented with a history of right leg claudication, which occurred after walking a distance of 500 m. The patient had no history of cardiovascular risk factors or trauma in the lower extremities. The ankle-brachial pressure index (ABI) was 0.58 in the affected leg. The patient was referred to the cardiovascular department. On Doppler ultrasonography, popliteal artery stenosis was detected. Following an angiogram, drug-coated balloon angioplasty was performed. The claudication improved, as indicated by an ABI of 1.11 in the affected leg. However, following one month of endovascular treatment, claudication had recurred, indicated by an ABI of 0.59. Computed tomography indicated the presence of a stenotic lesion in the popliteal artery, which may have developed from compression on the artery due to the presence of a surrounding periarterial cyst. The patient was subsequently diagnosed with cystic adventitial disease of the popliteal artery and was referred for vascular surgery. During surgery, the popliteal artery was exposed by the posterior approach; the artery showed circumferential enlargement and complete resection of the adventitial layer was performed. The patient had a successful postoperative recovery and the claudication disappeared (ABI of 1.14). Surgical management is an effective curative treatment for cystic adventitial disease of the popliteal artery that shows better efficacy than endovascular treatment. In the future, diagnostic methods for cystic adventitial disease should include computed tomography or magnetic resonance imaging with T1- and T2-weighted images.

Peroxisome proliferator-activated receptor-α expression is associated with histological type in human gastric carcinoma

Gastric carcinoma is one of the most common types of cancer worldwide and a leading cause of cancer-related mortality. Gastric carcinoma is histologically subdivided into differentiated and undifferentiated carcinoma, with the latter including poorly differentiated carcinoma and signet ring cell carcinoma (SRCC). Poorly differentiated carcinoma and SRCC have a worse prognosis compared with differentiated carcinoma. Peroxisome proliferator-activated receptors (PPARs) are nuclear hormone receptors and the PPAR-α subtype regulates important cellular functions, including cell proliferation, energy metabolism, oxidative stress, immune responses and cell differentiation. The aim of the present study was to elucidate the associations between clinicopathological factors and PPAR-α expression in patients with gastric carcinoma. The immunohistochemical staining of specimens obtained from 57 patients showed that PPAR-α expression was slightly weaker in undifferentiated carcinoma than in differentiated carcinoma (P<0.01). PPAR-α expression also significantly differed between poorly differentiated carcinoma (both positive and negative: 14/20, 70%) and SRCC (not expressed: 0/7, 0%) (P<0.01). However, PPAR-α expression was not significantly affected by age, lymph node invasion, venous invasion, lymph node metastasis, depth of invasion or stage. Collectively, the present results demonstrated that the downregulated expression of PPAR-α may play a key role in the biological transformation of tumors. Therefore, PPAR-α appears to be an important protein related to histology and may hold promise as a prognostic marker. Further studies with a larger number of subjects are needed to elucidate the relationship between PPAR-α expression and tumor progression and to analyze long-term clinical survival.

Overexpression of the PPAR-γ protein in primary Ta/T1 non-muscle-invasive urothelial carcinoma

Peroxisome proliferator-activated receptor-γ (PPAR-γ) is a well-known nuclear receptor that is activated in the nucleus to regulate several transcription factors. Its expression patterns have been examined in various types of cancer. The present study investigated the expression patterns of PPAR-γ in non-muscle-invasive urothelial carcinoma. The expression rates of PPAR-γ, p53 and Ki-67 were compared to determine whether PPAR-γ may be considered as an immunobiomarker for bladder cancer. The intensity and extent of PPAR-γ expression were evaluated in 79 cases of non-muscle-invasive urothelial carcinoma (30 cases of papillary carcinoma low-grade, 30 cases of high-grade and 19 cases of carcinoma in situ) and 30 non-malignant cases. The nuclear overexpression of PPAR-γ was frequently observed in non-muscle-invasive urothelial carcinoma (63/79 cases) but was rarely detected in non-malignant cases (2/30 cases). The histological proliferation types of non-muscle-invasive urothelial carcinoma revealed that PPAR-γ was more frequently overexpressed in papillary carcinoma (54/60 cases) than in carcinoma in situ (9/19 cases). Immunohistochemical staining demonstrated that PPAR-γ was more useful as an immunobiomarker than p53 or Ki-67 (diagnostic odds ratios; 55.13, 16.82 and 11.13, respectively). In summary, this study demonstrated that the expression patterns of PPAR-γ were associated with histological proliferation type and that PPAR-γ was expressed in the nuclei of papillary carcinoma cells. These findings suggested that immunohistochemical staining for PPAR-γ may be used to comprehensively detect non-muscle-invasive urothelial carcinoma.

A Case of T/NK-Cell Post-Transplantation Lymphoproliferative Disease 7 Years after Heart Transplantation

Post-transplant lymphoproliferative diseases (PTLD) are potentially fatal complications after cardiac transplantation. Most cases are Epstein–Barr virus (EBV)-related B-cell tumors, and reduction of immunosuppression treatment as well as the use of rituximab in combination with other chemotherapy are effective. However, patients with T/NK-cell PTLD post-cardiac transplantation are rarely reported. We had a patient with a fever that lasted for three weeks, with lung infiltrations and hepatosplenomegaly, who had EBV-associated hemophagocytosis 7 years after heart transplantation and was eventually diagnosed with T/NK-cell PTLD by autopsy. Although rare diseases, regular monitoring of EBV-DNA levels might be crucial for early diagnosis and treatment of PTLD.

Effects of pain-related catastrophic thinking, anxiety, and depression on pain intensity and quality of life in patients with knee and low back pain

[Purpose] We aimed to examine the effects of pain-related catastrophic thoughts and anxiety/depression on pain intensity and quality of life (QOL), and how these effects (relationships) vary with pain location, in outpatients with chronic pain. [Participants and Methods] We recruited 14 participants with low back pain (2 males and 12 females) and 14 with knee joint pain (3 males and 11 females). We used the following evaluation tools: the visual analog scale (to evaluate pain intensity), pain catastrophizing scale (in which scores are categorized into helplessness, rumination, and magnification), Hospital Anxiety and Depression Scale (for psychodynamic evaluation), and a questionnaire for QOL evaluation. [Results] There was no difference in pain intensity between the groups. The “low back pain” group showed a positive correlation between pain intensity and anxiety, while the “knee pain” group showed a positive correlation between pain intensity and helplessness. The “low back pain” group showed a negative correlation between health in QOL assessment items and helplessness, and between health and magnification. However, in the “knee pain” group, there was a negative correlation between health and rumination, between health and anxiety, and between positive mental attitude and magnification. [Conclusion] Mental status varied depending on the pain location, regardless of the intensity of the pain. This suggests that a psychological approach dependent on pain location is needed during physical therapy.

Interleukin-32 regulates downstream molecules and promotes the invasion of pancreatic cancer cells

Pancreatic cancer is a malignant neoplasm with high invasiveness and poor prognosis. In a previous study, a highly invasive pancreatic cancer cell line was established and found to feature enhanced interleukin-32 (IL-32) expression. However, whether IL-32 promotes the invasiveness by enhancing or suppressing the expression of IL-32 through regulating downstream molecules was unclear. To investigate the effect of IL-32, cells were established with high levels of expression or downregulated IL-32; their invasive ability was measured using a real-time measurement system and the expression of some candidate downstream molecules involved in invasion was evaluated in the two cell types. The morphological changes in both cell types and the localization of IL-32 expression in pancreatic cancer tissues were studied using immunohistochemistry. Among the several splice variants of IL-32, cells transfected with the ε isoform had increased invasiveness, whereas the IL-32-suppressed cells had reduced invasiveness. Several downstream molecules, whose expression was changed in the two cell types, were monitored. Notably, changes of E-cadherin, CLDN1, CD44, CTGF and Wnt were documented. The morphologies of the two cell types differed from the original cell line. Immunohistochemically, the expression of IL-32 was observed only in tumor cells and not in normal pancreatic cells. In conclusion, IL-32 was found to promote the invasiveness of pancreatic cancer cells by regulating downstream molecules.

Selexipag for the treatment of chronic thromboembolic pulmonary hypertension

Treatment options for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) remain limited. Selexipag, an oral selective IP prostacyclin-receptor agonist approved for pulmonary arterial hypertension, is a potential treatment option for CTEPH.In this multicentre, randomised, double-blind, placebo-controlled study, 78 Japanese patients with inoperable CTEPH or persistent/recurrent pulmonary hypertension after pulmonary endarterectomy and/or balloon pulmonary angioplasty were randomly assigned to receive placebo or selexipag. The primary endpoint was the change in pulmonary vascular resistance (PVR) from baseline to week 20. The secondary endpoints were changes in other haemodynamic parameters, 6-min walk distance (6 WMD), Borg Dyspnoea Scale score, World Health Organisation (WHO) functional class, EuroQol 5 dimensions 5-level and N-terminal pro-brain natriuretic peptide.The change in PVR was -98.2±111.3 dyn·s·cm^-5 and -4.6±163.6 dyn·s·cm^-5 in the selexipag and placebo groups, respectively (mean difference, -93.5 dyn·s·cm^-5; 95% confidence interval, -156.8, -30.3; p=0.006). The changes in cardiac index (p<0.001) and Borg Dyspnoea Scale score (p=0.036) were also significantly improved over placebo. 6WMD and WHO functional class were not significantly improved. The common adverse events in the selexipag group were corresponded to those generally observed following a prostacyclin analogue is administered.Selexipag significantly improved PVR and other haemodynamic variables in patients with CTEPH, although exercise capacity remained unchanged. Further large-scale investigation is necessary to prove the role of selexipag in CTEPH.

Predicted probabilities of brain injury after carbon ion radiotherapy for head and neck and skull base tumors in long-term survivors

BACKGROUND AND PURPOSE

We aimed to determine the risk factors for radiation-induced brain injury (RIBI¹) after carbon ion radiotherapy (CIRT) to predict their probabilities in long-term survivors.

MATERIALS AND METHODS

We evaluated 104 patients with head, neck, and skull base tumors who underwent CIRT in a regimen of 32 fractions and were followed up for at least 24 months. RIBI was assessed using the Common Terminology Criteria for Adverse Events.

RESULTS

The median follow-up period was 45.5 months; 19 (18.3 %) patients developed grade ≥2 RIBI. The maximal absolute dose covering 5 mL of the brain (D5ml) was the only significant risk factor for grade ≥2 RIBI in the multivariate logistic regression analysis (p = 0.001). The tolerance doses of D5ml for the 5% and 50% probabilities of developing grade ≥2 RIBI were estimated to be 55.4 Gy (relative biological effectiveness [RBE]) and 68.4 Gy (RBE) by a logistic model, respectively.

CONCLUSION

D5ml was most significantly associated with grade ≥2 RIBI and may enable the prediction of its probability.

The potential diagnostic significance of crypt differentiation in gastric dysplasia

AIMS

This study investigated the relationship between the differentiation of tumour cells into crypts, which is determined by cell differentiation into Paneth and neuroendocrine cells, and tumour infiltration in gastric dysplasia.

METHODS AND RESULTS

The lesions were endoscopically biopsied low-grade dysplasia (LGD), endoscopically resected high-grade dysplasia (HGD), or cancer with submucosal invasion. LGD (n = 32) displayed crypt differentiation across the entire width of the tumour in all cases. Crypt differentiation was identified as a characteristic of tumours with low biological malignancy. HGD (n = 40) included tumours with a mixture of areas with and without crypt differentiation (n = 25) and tumours with crypt differentiation throughout the entire width (n = 15). Of the cancers with submucosal invasion (n = 30), the morphological progression of HGD area with crypt differentiation, HGD area without crypt differentiation and invasive cancer without crypt differentiation was confirmed for 23 samples. In two lesions, invasive cancer without crypt differentiation developed from HGD without crypt differentiation throughout the tumour width. In five samples, well-differentiated tubular adenocarcinoma with crypt differentiation developed from HGD with crypt differentiation and invaded with lamina propria-like stroma.

CONCLUSIONS

Loss of crypt differentiation could be an objective indicator of infiltration in the progression of HGD to invasive cancer. The invasive potential of dysplasia depends on the presence or absence of crypt differentiation.

Intrahepatic Bile Duct Injury as a Hepatic Immune-Related Adverse Event after Immune-Checkpoint Inhibitor Treatment

The increased use of immune-checkpoint inhibitors to treat various types of cancer has increased the incidence of immune-related adverse events (irAEs). Hepatic irAEs are frequent and can lead to serious conditions. Among the various types of hepatic irAEs reported to date, bile duct injury has been shown refractory to steroid treatment. This study describes 2 patients with hepatic irAEs manifesting as intrahepatic bile duct injury. Immunostaining with antibodies to both CD8 and cytokeratin-7 was useful for the diagnosis, and both patients were refractory to steroid treatment. Prompt diagnosis and active immunosuppressive therapies are required in such cases.

Endoscopic Ultrasound-guided Fine Needle Aspiration for the Diagnosis of Duodenal Stenosis Due to Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) initially presents with hematuria and hydronephrosis. We report a case of UTUC presenting with initial findings of duodenal stenosis before the appearance of hydronephrosis. A 59-year-old man presented with upper abdominal symptoms on his initial visit. Esophagogastroduodenoscopy (EGD) revealed circumferential stenosis at the descending part of the duodenum. However, the underlying cause of duodenal stenosis was unknown as repeated histopathological examinations of endoscopic biopsy specimens showed no specific findings. We then performed endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of the thickened duodenal wall, and successfully diagnosed duodenal metastasis of UTUC. EUS-FNA is an effective diagnostic method in cases in which the cause of duodenal stenosis is unknown.

Preoperative nutritional status is independently associated with wound healing in patients undergoing open surgery for ischemic tissue loss

OBJECTIVES

The aim of this study was to determine the relationship between preoperative nutritional status and wound healing in patients undergoing surgical reconstruction for ischemic tissue loss.

METHODS

The preoperative nutritional status of patients who underwent surgical reconstruction for ischemic tissue loss for the years 2011-2018 was retrospectively estimated using the Controlling Nutritional Status (CONUT) score. Patients were allocated to two groups: Group I, normal nutrition or mild malnutrition (CONUT score ≤4), and Group II, moderate-to-severe malnutrition (CONUT score ≥5). Wound healing was set as the primary endpoint and major amputation and death as the secondary endpoints. The wound healing, limb salvage, and overall survival rates were calculated after two years using the Kaplan-Meier method, and Cox proportional hazards regression analysis was performed to determine which variables were independently associated with these outcomes.

RESULTS

Forty-eight patients with missing values for the CONUT score were excluded. A total of 174 limbs in 147 patients were studied (Group I: 115 limbs in 100 patients; Group II: 59 limbs in 47 patients). The mean duration of the study was 519 ± 270 days. The Kaplan-Meier curves showed that wound healing in Group I was superior to that in Group II (Group I vs. II: two-year wound healing, 97% vs. 79%; time to 50% wound healing, 83 vs. 150 days, p < 0.001), and multivariate analysis showed that the CONUT score was an independent predictor of wound healing (hazard ratio, 0.63; 95% confidence interval, 0.41-0.98; p = 0.038).

CONCLUSIONS

Patients with better preoperative nutritional status are more likely to experience wound healing earlier than those with excessive malnutrition.

A case of pancreatic arteriovenous malformation caused acute pancreatitis

Arteriovenous malformation (AVM) in the pancreas rarely causes acute pancreatitis. However, even when it does cause pancreatitis, the pathogenesis is unclear. A 61-year-old man was admitted to our hospital for acute pancreatitis. The findings of computed abdominal tomography, magnetic resonance imaging, and endoscopic ultrasonography revealed pancreatic AVM and hematoma in the tail of the pancreas. These lesions were suspected to be associated with pancreatitis. Although endoscopic retrograde pancreatography could not confirm hemosuccus pancreaticus, distal pancreatectomy was performed because of repeated pancreatitis. The histopathological findings of the resected specimen revealed rupture of the AVM vessels into the main pancreatic ducts. Finally, we considered that intermittent bleeding due to AVM rupture and hematoma formation in the main pancreatic duct caused the repeated pancreatitis.

CD8 Positive T Lymphocyte Infiltration of Liver Metastases of Uveal Melanoma: A Case Report

A 78-year-old Japanese man was referred for examination of multiple small nodules on his liver detected by magnetic resonance imaging (MRI). These small nodules were hyperintense on T1-weighted MRI, and were in hepatobiliary phase on gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid enhanced MRI. Five years earlier, he had undergone curative enucleation of his left eye for uveal melanoma. US-guided biopsy revealed that the liver nodules were metastases of melanoma. Pathological examination also showed infiltration of CD8 positive T lymphocytes. The metastatic nodules remained unchanged for more than 2 years and he was not further treated. This pathology and clinical course suggest that the systemic immune response of the host could suppress hepatic metastases of uveal melanoma.

Salvage of Infected Prosthetic Grafts at the Groin or Thigh Using Muscle Flap Coverage

Objectives: This study aimed to evaluate early- and long-term outcomes in patients who undergo muscle flap coverage (MFC) for prosthetic graft infections (PGIs) at the groin or thigh.

Materials and Methods: We retrospectively retrieved and analyzed data on infected wound cures, recurrence, graft and limb salvage, and survival of patients who underwent MFC for PGI at the groin or thigh between 2000 and 2018.

Results: There were eight patients in our cohort: six had groin PGIs and two had thigh PGIs. Moreover, of these patients, seven were treated from sartorius muscles and one from a gracilis muscle. The indicated wounds healed in all eight patients, but two patients died during hospitalization. Three patients suffered recurrence within 8 months, one of which overcame the infection and achieved wound cure without graft removal, with negative pressure wound therapy. No patients lost their limbs during the follow-up term (mean, 24 months; range, 1–60 months). Finally, four patients (50%) survived without removal of the infected graft for longer than 2 years.

Conclusion: MFC can be a curative treatment for PGI, but there remains a possibility of a recurring infection thereafter.

Diagnosis by molecular pathology of an early and atypical histoplasmosis lesion in the duodenum of an immunocompromised patient: A case report

Histoplasmosis is a fungal infection caused by Histoplasma capsulatum (HC), which can occasionally be aggressive resulting in the formation of granulomatous lesions. These are usually located in the lungs; however, immunocompromised patients may occasionally develop disseminated lesions in other organs as well. Human immunodeficiency virus (HIV) primarily infects cells of the immune system expressing CD4 molecules. Not only does HIV multiply within these cells, but it can also kill them or otherwise cause loss of cellular function, leading to an immunocompromised state. As a result, in an immunocompromised patient, infection with HC can have serious implications, often the development of visceral histoplasmosis in different organs. Although several types of lesions are formed in HC-infected organs, it may be difficult to distinguish the causative organism from other pathogens based on morphology alone. The present case report describes the case of a 57-year-old woman, from South America, who may have been infected with HC >20 years previously, remaining asymptomatic over the years. She later developed a lesion in the duodenum associated with immunodeficiency caused by HIV infection. The differential diagnosis of this case was made on the basis of several specific morphological findings using histopathological analysis and molecular pathological techniques. The pathogenesis of characteristic lesions caused by HC in the presence of HIV infection was also reviewed.

Expression of laminin-5 gamma 2 chain predicts invasion of extramammary Paget's disease cell

Extramammary Paget's disease (EMPD) is a rare malignant skin neoplasm characterized by intraepidermal proliferation of tumor cells. The tumor cells of EMPD may sometimes invade into the dermis or metastasize into the regional lymph nodes. Several studies have proposed mechanisms underlying the increased invasiveness of EMPD; however, molecular markers indicating invasiveness have yet to be well characterized. Laminin-5 (Lam-5), a heterotrimer composed of three chains (α3, β3, and γ2), is a major component of the basement membrane in many tissues. One of the chains, Lam-5 γ2, is a marker of invasion, because it often develops as a monomer in malignant neoplasms. We investigated the expression of Lam-5 γ2 and its role for the invasiveness in EMPD. Paraffin-embedded specimens of EMPD obtained from 36 patients were examined immunohistochemically for Lam-5 γ2. The cases adopted into this study comprised 16 cases of intraepidermal lesions and 20 cases with dermal invasion. The basement membrane seen in normal skin disappeared in one-third of non-invasive cases and in most invasive cases. The disappearance of Lam-5 γ2 in the basement membrane and its cytoplasmic expression was more observed in the invasive cases than non-invasive cases. Expression of Lam-5 γ2 may be a biological marker to predict invasiveness of EMPD.

Red-Fluorescent Pt Nanoclusters for Detecting and Imaging HER2 in Breast Cancer Cells

Overexpression of human epidermal growth factor receptor 2 (HER2) is associated with more frequent cancer recurrence and metastasis. Sensitive sensing of HER2 in living breast cancer cells is crucial in the early stages of cancer and to further understand its role in cells. Biomedical imaging has become an indispensable tool in the fields of early cancer diagnosis and therapy. In this study, we designed and synthesized platinum (Pt) nanocluster bionanoprobes with red emission (Ex/Em = 535/630 nm) for fluorescence imaging of HER2. Our Pt nanoclusters, which were synthesized using polyamidoamine (PAMAM) dendrimer and preequilibration, exhibited approximately 1% quantum yield and possessed low cytotoxicity, ultrasmall size, and excellent photostability. Furthermore, combined with ProteinA as an adapter protein, we developed Pt bionanoprobes with minimal nonspecific binding and utilized them as fluorescent probes for highly sensitive optical imaging of HER2 at the cellular level. More importantly, molecular probes with long-wavelength emission have allowed visualization of deep anatomical features because of enhanced tissue penetration and a decrease in background noise from tissue scattering. Our Pt nanoclusters are promising fluorescent probes for biomedical applications.

Development of a Surgical Sponge Counting System Using Radiographic Images

Background. Retention of surgical sponges in patients is a relatively frequent medical malpractice. To prevent it, the surgical sites are scanned using X-ray. However, using radiography in the operation room induces X-ray exposure for both patients and staff. To prevent such issues, a novel sponge counting system was developed. Each surgical sponge used in common hospitals is composed of single radiopaque fibers. Methods. The proposed system scans surgical sponges to estimate their fiber length (EFL) and returns the number of it. In this study, an optimal image acquisition protocol was determined that allows an accurate count of sponges. X-ray doses and multi-angle image procedures were tested. Results. Measurement trials were performed and compared for both dry and blood-soaked sponges. As a result, the X-ray dose of 50 kV and 600 μA and the acquisition of 180 images per sample yielded an accurate EFL. The 180-image protocol achieved good performance in this study and allowed counting of one package of 10 sponges in 226 seconds. For these settings, a significant correlation was found between the actual number of sponges and the estimated fiber lengths. Additionally, the performance of the system was similar for either dry or blood-soaked items. Conclusion. The proposed system could accurately count surgical sponges and is a promising option in preventing the accidental retention of surgical sponges.

Establishment of highly invasive pancreatic cancer cell lines and the expression of IL-32

Compared to tumors of other organs, pancreatic cancer is highly aggressive; with one of its biological features being that, despite a prominent fibrotic stroma, there is remarkable infiltration of tumor cells. This characteristic is considered to be the main reason for the poor prognosis of patients with pancreatic cancer. Therefore, in order to elucidate the factors that contribute to this high invasiveness, a selective invasion method was used to establish four highly invasive subclones from six human pancreatic cancer cell lines. The results demonstrated that two cell lines did not exhibit enhanced invasiveness. Microarray analysis revealed that, in the highly invasive cell lines, several genes were expressed at high levels, compared with the original cell lines. These highly expressed genes were recognized only in highly invasive cells. Among them, IL-32 was most strongly upregulated in the highly invasive cells, compared with cells with a low invasive potential, as well as the original cells. RT-qPCR and western blot analysis confirmed the high levels of expression of IL-32 in highly invasive cells at the RNA and protein levels. In addition, immunohistochemical analysis of resected surgical materials revealed that the tumor cells expressed IL-32 and, in particular, many IL-32 positive cells were seen at the invasive front of the tumor tissue. IL-32 is a cytokine that is widely involved in the development of cancer and has recently received considerable attention. This cytokine has multiple splice variants and shows a wide variety of behaviors, depending on the tumor type and primary organ. Although some hypotheses have been proposed to explain the activity of IL-32, a unified view has not been agreed. In the present study, through the establishment of highly invasive cells from pancreatic cancer and a comprehensive gene analysis, it is suggested that IL-32 may serve an important role as a molecule involved in the invasiveness of this neoplasm.

Computed tomographic analysis of internal structures within the nasal cavities of green, loggerhead and leatherback sea turtles

The morphology of the tetrapod nasal cavity has adapted to the environment in terms of olfaction and respiration. Reports indicate that the internal structure of the nasal cavity of green sea turtles is more complex than that of turtles in general, but whether or not it is similar among sea turtle species remains unknown. The present study aimed to define the internal structures of the nasal cavity of green (Chelonian mydas), loggerhead (Caretta caretta) and leatherback (Dermochelys coriacea) sea turtles using computed tomography. The nasal cavity of green and loggerhead sea turtles contained anterodorsal, anteroventral, posterodorsal diverticula and a posteroventral excavation in the middle. In contrast, the nasal cavity of leatherback sea turtles had more complicated dorsal region comprising anterodorsal and posterodorsal diverticula, and two excavations between the nostril and anterodorsal diverticulum, but no distinct structures at the ventral region. The airway in the nasal cavity was shorter and thicker in the leatherback, than in the green and loggerhead turtles. These species differences might reflect ecological variety and different evolutionary strategies.

Restricted mean survival time as a summary measure of time-to-event outcome

Many clinical research studies evaluate a time-to-event outcome, illustrate survival functions, and conventionally report estimated hazard ratios to express the magnitude of the treatment effect when comparing between groups. However, it may not be straightforward to interpret the hazard ratio clinically and statistically when the proportional hazards assumption is invalid. In some recent papers published in clinical journals, the use of restricted mean survival time (RMST) or τ-year mean survival time is discussed as one of the alternative summary measures for the time-to-event outcome. The RMST is defined as the expected value of time to event limited to a specific time point corresponding to the area under the survival curve up to the specific time point. This article summarizes the necessary information to conduct statistical analysis using the RMST, including the definition and statistical properties of the RMST, adjusted analysis methods, sample size calculation, information fraction for the RMST difference, and clinical and statistical meaning and interpretation. Additionally, we discuss how to set the specific time point to define the RMST from two main points of view. We also provide developed SAS codes to determine the sample size required to detect an expected RMST difference with appropriate power and reconstruct individual survival data to estimate an RMST reference value from a reported survival curve.

Perforation of the Small Intestine after Introduction of Lenvatinib in a Patient with Advanced Hepatocellular Carcinoma

Lenvatinib is a first-line standard treatment for advanced hepatocellular carcinoma (HCC) with better anti-tumor effects than sorafenib, as shown by greater inhibition of the kinases of fibroblast growth factor receptor and vascular endothelial growth factor (VEGF) receptor. This report describes a patient with advanced HCC who experienced perforation of the small intestine 1 month after starting the treatment with lenvatinib. This patient likely had partial necrosis of a metastasis to the small intestine before starting lenvatinib treatment, with subsequent ischemic changes leading to perforation of the small intestine. Although metastasis of HCC to the small intestine is rare, patients with these metastases should be regarded as being at risk for perforation during lenvatinib treatment.

Superior mesenteric artery dissection with prolonged abdominal angina treated by laparotomy, endarterectomy, patch angioplasty, and retrograde open mesenteric stenting: a case report

BACKGROUND

Most patients with isolated superior mesenteric artery (SMA) dissection are successfully managed conservatively. However, some patients require more invasive treatment.

CASE PRESENTATION

We herein describe a 45-year-old man with isolated SMA dissection. He initially underwent conservative treatment. However, because of persistent abdominal angina, we considered the need for surgical revascularization. He was successfully treated by endarterectomy, patch angioplasty, and retrograde open mesenteric stenting. The abdominal angina was stabilized thereafter.

CONCLUSIONS

The combination of endarterectomy, patch angioplasty, and retrograde open mesenteric stenting is useful for isolated SMA dissection, and long patency can be expected for some patients.

[Quality Control of Medical Instruments and Cleaning Water]

PURPOSE

Herein we aimed to investigate the degradation of surgical instruments in our hospital and how water quality affects the rate of metal corrosion.

MATERIALS AND METHODS

We observed 279 stainless steel instruments, and determined the presence of damage like metal corrosion or scale formation. We also measured the concentrations of chloride(Cl^-)and silicate(SiO₄^4-)ions in the water used for cleaning in our operating rooms, including tap water from the city water supply and reverse-osmosis(RO)filtered water.

RESULT

Pitting corrosion was observed on 71% of the instruments we investigated. The concentration of Cl^- was 0.7mg/L in tap water and 0.1mg/L in RO water, while the concentration of SiO₄^4- was 0.3mg/L in both the tap and RO water.

DISCUSSION

Of the dissolved ions Cl^- and SiO₄^4-, Cl^- is more of a concern, as it causes pitting corrosion over time, while SiO₄^4- causes scale formation. Considering the typical water quality in the operating-room environment, degradation must be monitored for the general maintenance of metal surgical instruments.

BubR1 Insufficiency Results in Decreased Macrophage Proliferation and Attenuated Atherogenesis in Apolipoprotein E-Deficient Mice

Background

Budding uninhibited by benzimidazole‐related 1 (BubR1), a cell cycle–related protein, is an essential component of the spindle checkpoint that regulates cell division. BubR1 insufficiency causes early aging‐associated vascular phenotypes. We generated low‐BubR1‐expressing mutant (BubR1^L/L) and apolipoprotein E‐deficient (ApoE^−/−) mice (BubR1^L/L‐ApoE^−/− mice) to investigate the effects of BubR1 on atherosclerosis.

Methods and Results

Eight‐week‐old male BubR1^L/L‐ApoE^−/− mice and age‐matched ApoE^−/− mice were used in this study. Atherosclerotic lesion development after being fed a high‐cholesterol diet for 12 weeks was inhibited in BubR1^L/L‐ApoE^−/− mice compared with ApoE^−/− mice, and was accompanied by decreased accumulation of macrophages. To address the relative contribution of BubR1 on bone marrow–derived cells compared with non‐bone marrow–derived cells, we performed bone marrow transplantation in ApoE^−/− and BubR1^L/L‐ApoE^−/− mice. Decreased BubR1 in bone marrow cells and non‐bone marrow–derived cells decreased the atherosclerotic burden. In vitro assays indicated that decreased BubR1 expression impaired proliferation, but not migration, of bone marrow–derived macrophages.

Conclusions

BubR1 may represent a promising new target for regulating atherosclerosis.

A Rare Complication of Spinal Cord Ischemia Following Endovascular Aneurysm Repair of an Infrarenal Abdominal Aortic Aneurysm with Arteriosclerosis Obliterans: Report of a Case

We herein report a case of a rare complication of spinal cord ischemia (SCI) following endovascular aneurysm repair (EVAR). Computed tomography showed stenosis and calcification of bilateral iliac arteries and a saccular aneurysm of the terminal aorta. Paraplegia occurred soon after balloon angioplasty of iliac arteries and EVAR. Cerebrospinal fluid drainage was not performed because the patient was on dual antiplatelet drugs. The patient was treated with intravenous methylpredonisolone and naloxone; however, this did not improve his paraplegia. SCI after EVAR is extremely rare and unpredictable complication, however, physicians should be aware of SCI after EVAR in patients with atherosclerosis.

Prognostic factor of the two-year mortality after revascularization in patients with critical limb ischemia

Purposes

The aim of this study was to evaluate the risk factors for the two-year survival after revascularization of critical limb ischemia.

Methods

Between 2008 and 2012, 142 patients underwent revascularization. A retrospective analysis was performed to measure the risk factor.

Results

A total 85 patients underwent surgical revascularization, 31 patients underwent endovascular therapy while 26 patients underwent hybrid therapy. By multivariate analysis, the following variables were considered to be risk factors: ejection fraction <50 % (HR, 3.14; 95% CI, 1.22–7.95; P = 0.02), serum albumin level <2.5 g/dL (HR, 3.45; 95% CI, 1.01–11.7; P = 0.04) and nonambulatory status (HR, 4.11; 95% CI, 1.79–9.70; P < 0.01). The two-year survival rate of the patients with no risk factors was 85.5%, while the patients with at least one risk factor had an unfavorable prognosis (one; 56.7%, two; 45.4%).

Conclusions

The nonambulatory status, serum albumin level <2.5 g/dL and ejection fraction <50% were the risk factors for the two-year mortality after revascularization in critical limb ischemia patients. These risk factors may be useful for the treatment strategy of critical limb ischemia patients.

Radial forces of stents used in thoracic endovascular aortic repair and bare self-expanding nitinol stents measured ex vivo – Rapid rescue for obstruction of the innominate artery using bare self-expanding nitinol stents

Purpose

Our objective was to compare the radial forces of several stents ex vivo to identify stents suitable for rescue of the unexpected coverage of aortic arch branches in thoracic endovascular aortic repair.

Methods

We measured the radial forces of two types of self-expanding bare nitinol stents (E-luminexx and Epic) used singly or as double-walled pairs, and of three endoprostheses used in thoracic endovascular aortic repair (TEVAR, Gore c-TAG, Relay, and Valiant) by compressing the stent using an MTS Instron universal testing machine (model #5582). We also examined the compressive effects of the TEVAR endoprostheses and the bare nitinol stents on each other.

Results

The radial force was greater in the center than at the edge of each stent. In all stents tested, the radial force decreased incrementally with increasing stent diameter. The radial force at the center was two times greater when using two stents than with a single stent. In the compression test, only E-luminexx used as a pair was not compressed after compressing a Relay endoprosthesis by 12 mm.

Conclusion

Two E-luminexx stents are appropriate to restore the blood flow if a TEVAR endoprosthesis covers the innominate artery following innominate–carotid–left subclavian arterial bypass.

[Efficacy and Prognostic Factors of Estracyt ® in Patients with Castration-Resistant Prostate Cancer (CRPC) : From the Data Analysis of Estracyt ® Special Drug Use Investigation]

Estracyt○R (estramustine phosphate) is a medical drug for prostate cancer with cytotoxic activity causing disruption of microtubule organization and indirect androgen production suppressing activity by its metabolite, estradiol. Based on the data obtained from the Estracyt○R Special Drug Use Investigation which surveyed the clinical efficacy and safety of Estracyt○R in patients with prostate cancer whose relapse of prostate cancer after combined androgen blockade (CAB) therapy was confirmed, we evaluated the progression-free survival, prognostic factor, decrease in prostate specific antigen (PSA) level and safety. This surveillance was conducted at 147 institutions nationwide between October, 2010 and September, 2013 and clinical efficacy was evaluated in 239 cases and safety in 329 cases. The median duration of progression-free survival, PSA progression-free survival and PSA response were 169 days (95%CI, 142-190), 197 days (95%CI, 169-267) and 385 days, respectively. The decrease in PSA level was observed in 125 cases (52.3%). Rate of PSA decline ＞50 and ＞25% were 18.4 and 43.1, respectively, and rate of PSA best response (PSA decline ＞ 50%) was 32.6%. Multivariate analysis demonstrated that long duration of prior CAB therapy, Estracyt○R - pretreatment PSA value and bone metastasis influenced progression-free survival significantly. Adverse events were observed in 127 cases (38.6%). The major adverse events were anorexia which was observed in 35 cases (10.9%), gastrointestinal disorders observed in 32 cases (9.7%), abnormal laboratory test values observed in 31 cases (9.4%) and gynecomastia observed in 16 cases (4.9%). These results suggest the clinical efficacy and safety of Estracyt○R for chemotherapy-naïve castration-resistant prostate cancer (CRPC), and Estracyt○R is regarded as one of the treatment options for patients with CRPC, especially for patients who had long duration of prior CAB therapy.