Subxiphoid robot-assisted complete resection for postchemotherapy primary mediastinal yolk sac tumour.

The standard treatment for primary mediastinal yolk sac tumour involves neoadjuvant chemotherapy followed by residual tumour resection, typically performed through a median sternotomy or a thoracotomy. However, in this case, a 16-year-old patient with a large anterior mediastinal tumour underwent less invasive, subxiphoid, robot-assisted surgery using a 4-arm da Vinci Xi system with CO2 insufflation at 8 mmHg. The tumour, located in the right thymic lobe, was dissected using a technique similar to blunt dissection, bipolar electrocautery and vessel sealer. Pericardiotomy was performed suspecting tumour invasion, with the thickened pericardial border incised circularly from the left side. Preservation of the right phrenic nerve involved careful separation from the densely adherent tumour. A pulmonary wedge resection was also performed using a stapler. The pericardial defect was reconstructed using an expanded polytetrafluoroethylene sheet, sutured together with nylon threads, and the resected tumour was extracted with a retrieval bag. This subxiphoid robot-assisted approach is a minimally invasive option for malignant mediastinal tumours.

Breakpoint analysis for cytogenetically balanced translocation revealed unexpected complex structural abnormalities and suggested the position effect for MEF2C.

Many disease-causing genes have been identified by determining the breakpoints of balanced chromosomal translocations. Recent progress in genomic analysis has accelerated the analysis of chromosomal translocation-breakpoints at the nucleotide level. Using a long-read whole-genome sequence, we analyzed the breakpoints of the cytogenetically balanced chromosomal translocation t(5;15)(q21;26.3), which was confirmed to be of de novo origin, in a patient with a neurodevelopmental disorder. The results showed complex rearrangements with seven fragments consisting of five breakpoint-junctions (BJs). Four of the five BJs showed microhomologies of 1-3-bp, and only one BJ displayed a signature of blunt-end ligation, indicating chromothripsis as the underlying mechanism. Although the BJs did not disrupt any disease-causing gene, the clinical features of the patient were compatible with MEF2C haploinsufficiency syndrome. Complex rearrangements were located approximately 2.5-Mb downstream of MEF2C. Therefore, position effects were considered the mechanism of the occurrence of MEF2C haploinsufficiency syndrome.

A Case of Acute Encephalopathy Associated with Acute Focal Bacterial Nephritis.

Acute encephalopathy is a syndrome characterized by an acute onset of disturbance of consciousness. Many acute encephalopathies are caused by viral infections; however, they can also be a result of bacterial infections. Acute focal bacterial nephritis (AFBN) can cause neurological symptoms, such as irritation, unconsciousness, and seizures. In some cases, AFBN-associated acute encephalopathy has also been reported. This report describes the first case of acute encephalopathy with AFBN without significant findings on brain MRI. The patient was a 3-year-old male, who had two episodes of febrile seizures at the ages of 1 and 2 years. He developed disturbance of consciousness, irritability, excitability, and neck stiffness on the day after admission. There were no abnormal findings on brain MRI; however, a generalized high-voltage slow wave was noted on electroencephalography (EEG). His urinary sediment count was elevated, and Morganella morganii and Enterococcus faecalis were detected in the urinary culture. A diagnosis of acute encephalopathy with urinary tract infection (UTI) was made. Intravenous (IV) antibiotics were administered to treat the UTI, while methylprednisolone pulse therapy and IV immunoglobulin were administered to treat acute encephalopathy. Additionally, AFBN was detected in both kidneys on contrast-enhanced CT. The patient received a second course of methylprednisolone pulse therapy due to the persistent high voltage slow wave noted on the EEG on day 8. Furthermore, contrast-enhanced CT revealed AFBN in both kidneys. The final diagnosis was acute encephalopathy with AFBN; however, we had initially diagnosed febrile seizures associated with UTI. It should be noted that acute encephalopathy is associated with AFBN.

Mutation in the STXBP1 Gene Associated with Early Onset West Syndrome: A Case Report and Literature Review.

Syntaxin-binding protein1 (STXBP1) is a member of the Sec1/Munc18-1 protein family, which comprises important regulators of the secretory and synaptic vesicle fusion machinery underlying hormonal and neuronal transmission, respectively. STXBP1 pathogenic variants are associated with multiple neurological disorders. Herein, we present the case of a Japanese girl with a mutation in the STXBP1 gene, who was born at 40 weeks without neonatal asphyxia. At 15 days old, she developed epilepsy and generalized seizures. Around 88 days old, she presented with a series of nodding spasms, with the seizure frequency gradually increasing. Interictal EEG indicated hypsarrhythmia and she presented with developmental regression. At 1.5 years old, genetic testing was performed and mutational analysis revealed an STXBP1 gene mutation (c.875G > A: p.Arg292His). Accordingly, she was diagnosed with developmental and epileptic encephalopathy, presenting West syndrome's clinical characteristics caused by the STXBP1 gene mutation. Although drug treatment has reduced the frequency of epileptic seizures, her development has remained regressive. The relationship between the location and type of genetic abnormality and the phenotype remains unclear. Future studies should investigate the genotype−phenotype correlation and the underlying pathophysiology to elucidate the causal relationships among the multiple phenotype-determining factors.

Recurrent de novo pathogenic variant of WASF1 in a Japanese patient with neurodevelopmental disorder with absent language and variable seizures.

A recurrent de novo pathogenic variant of WASF1, NM_003931:c.1516C>T [p.Arg506*], was identified in a 6-year-old female Japanese patient with severe developmental delay, hypotonia, hyperkinetic behavior, and distinctive facial features. The initial report of five adult patients with WASF1 variants was the only previous report regarding variants of this gene; this is the second such report, reaffirming that rare but recurrent truncating variants of WASF1 are associated with severe neurodevelopmental disorders.

HECW2-related disorder in four Japanese patients.

The HECT, C2, and WW domain containing E3 ubiquitin protein ligase 2 gene (HECW2) is involved in protein ubiquitination. Several genes associated with protein ubiquitination have been linked to neurodevelopmental disorders. HECW2-related disorder has been established through the identification of de novo variants in HECW2 in patients with neurodevelopmental disorders with hypotonia, seizures, and absent language. Recently, we identified novel HECW2 variants in four Japanese patients with neurodevelopmental disorders. Regarding motor development, two of the patients cannot walk, whereas the other two can walk with an unsteady gait, owing to hypotonia. All HECW2 variants, including those that were previously reported, are missense, and no loss-of-function variants have been identified. Most of the identified variants are located around the HECT domain. These findings suggest that the dominant negative effects of missense variants around the HECT domain may be the mechanism underlying HECW2-related disorder.

Efficacy of preoperative inhaled LAMA/LABA combinations in patients with lung cancer and untreated COPD.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with a high incidence of postoperative pulmonary complications (PPCs). When untreated COPD is found before lung cancer surgery, we have been actively intervening therapeutically with inhaled long-acting muscarinic antagonist (LAMA)/long-acting ß2-agonist (LABA) combinations. We investigated the efficacy of preoperative LAMA/LABA treatment. METHODS: We reviewed data from 261 patients who underwent pulmonary resection for primary lung cancer. Of these, 59 patients showed unrecognized obstructive ventilatory impairment on respiratory function testing. We administered inhaled drugs for 38 patients, of whom 22 patients treated with LAMA/LABA combinations and diagnosed with COPD were retrospectively analyzed regarding improvement of respiratory function and postoperative course. RESULTS: Median duration of LAMA/LABA treatment was 19.5 days (interquartile range (IQR), 10.5-28.3 days). Percentage predicted vital capacity (%VC) (pretreatment: 95.6%, IQR 91.9-111.7 vs. posttreatment 102.8%, IQR 92.3-113.0), forced expiratory volume in 1 s (FEV1) (1.76 L, 1.43-2.12 vs. 2.00 L, 1.78-2.40), forced VC (FVC) (2.96 L, 2.64-3.47 vs. 3.22 L, 2.95-3.74) and percentage predicted FEV1 (80.1%, 68.4-97.0 vs. 91.6%, 80.3-101.9) were all significantly improved (P<0.05 each). FEV1/FVC tended to be improved, but not significantly. No significant difference in improvement of respiratory function was seen between short-term (≤2 weeks) and normal-term (>2 weeks) treatment. PPCs occurred in 4 of 22 patients (18.2%), showing no significant difference compared to patients with COPD previously treated with inhaled drugs (2/20; 10.0%). CONCLUSIONS: Respiratory function is improved by preoperative LAMA/LABA treatment even in the short term. Starting treatment allows even COPD patients diagnosed on preoperative screening to experience the same frequency of PPCs as previously treated patients.

HPeV3-associated acute encephalitis/encephalopathy among Japanese infants.

OBJECTIVE: The current study aimed to identify and compare the clinical characteristics of human parechovirus type 3 (HPeV3)-associated acute encephalitis/encephalopathy (HPeV3E/E) between infants with abnormal brain magnetic resonance imaging (MRI) findings (typical, or MRI-positive HPeV3E/E) and those with MRI-negative findings (MRI-negative HPeV3E/E). METHODS: This is a retrospective study on patients with HPeV3 infection, and a two-step questionnaire survey performed on 837 hospitals in Japan between 2014 and 2016. RESULTS: We identified 240 infants with HPeV3 infection, of which 34 had been clinically-diagnosed HPeV3E/E (cHPeV3E/E). However, detailed clinical data were provided by 32 of the 34 patients. Among these 32, 23 had undergone MRI and were categorized into two groups, MRI-positive (n = 17) and -negative (n = 6). There were no significant intergroup differences in clinical lab results or symptoms, except for gastrointestinal symptoms that were only present in the MRI-negative patients. The MRI-positive group showed white matter involvement on brain MRI during the acute phase, and 8 patients presented with lesions on follow-up MRI. Furthermore, 4 (50%) of the 8 patients had neurological sequelae. CONCLUSION: Clinical characteristics of cHPeV3E/E patients with and without lesions on brain MRI showed no significant differences. Therefore, considering the difficulty in distinguishing febrile infants with cHPeV3E/E from those with a sepsis-like illness, during an HPeV3 infection epidemic, it is imperative to frequently perform brain MRI in febrile infants presenting with severe disease for the early diagnosis of HPeV3E/E presenting with brain lesions.

High-amplitude fast activity in EEG: An early diagnostic marker in children with beta-propeller protein-associated neurodegeneration (BPAN).

OBJECTIVE: The early diagnosis of beta-propeller protein-associated neurodegeneration (BPAN) before distinct brain magnetic resonance imaging (MRI) findings of iron deposition occur remains challenging. This study examined whether children with BPAN have characteristic high-amplitude (>50 µV) fast activity (HAFA) on electroencephalography (EEG). METHODS: We conducted a retrospective analysis of EEG performed during childhood in five patients with BPAN. We also examined 143 EEGs from 59 patients with different etiologies, including epilepsy (n = 33), acute encephalopathy (n = 6), neurodevelopmental disorders (n = 5), non-epileptic events (n = 4), and others (n = 11). Trained electroencephalographers reviewed all of the EEGs. When excessive fast activity was observed, the amplitude, frequency, and locality were assessed. RESULTS: All five patients with BPAN underwent initial EEGs at 12-21 months old, and diffuse continuous HAFA (range 20-50 Hz) was observed on both awake and sleep EEGs. In the awake records, there was no clear posterior dominant rhythm in 4 of the 5 patients. Although 28% of the 143 EEGs had continuous excessive fast activity, mainly in the sleep records, only two (1.4%) exhibited HAFA when asleep, and their awake EEGs had clear posterior dominant rhythm. CONCLUSIONS: The EEGs of children with BPAN showed diffuse HAFA continuously when both awake and asleep, which is uncommon in children with other etiologies. SIGNIFICANCE: This study provides an important clue for the early diagnosis of BPAN.

Clinical features of early myoclonic encephalopathy caused by a CDKL5 mutation.

BACKGROUND: CDKL5 deficiency is caused by mutations in the cyclin-dependent kinase-like 5 (CDKL5) gene and clinically manifests often in females as drug-resistant intractable epilepsy and severe psychomotor retardation. CASE REPORT: We report the case of a girl with a CDKL5 mutation born at 39 weeks without neonatal asphyxia. She developed epilepsy at age 1 month with myoclonus of the face and limbs, and non-rhythmic and irregular opsoclonus. She developed tonic seizures and epileptic spasms at 6 months of age and was diagnosed with symptomatic West syndrome and underwent adrenocorticotropic hormone therapy but her seizures were refractory. At the age of 4, she was introduced to our hospital and development was at 2 months of age. We diagnosed her with early myoclonic encephalopathy (EME) due to the remaining suppression-burst pattern observed on an electroencephalogram and her symptoms since onset were mainly myoclonus. At 14 years of age, mutational analysis revealed a CDKL5 mutation (c.380A > G:p.His127Arg). She was diagnosed with epileptic encephalopathy exhibiting clinical features of early myoclonic epilepsy caused by CDKL5 deficiency. CONCLUSIONS: Early onset epilepsy with severe psychomotor retardation without a known etiology may be caused by a mutation in CDKL5. More research investigating a genotype-phenotype correlation of CDKL5 mutations is necessary because clinical severity may be associated with the location and type of mutations.

Preoperative screening for nasal carriage of methicillin-resistant Staphylococcus aureus in patients undergoing general thoracic surgery.

Objectives: Nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) is a risk factor for surgical site infections (SSIs). However, few studies have evaluated the rate of nasal carriage of MRSA and its effect on SSIs in patients undergoing general thoracic surgery. We investigated the importance of preoperative screening for nasal carriage of MRSA in patients undergoing general thoracic surgery. Patients and Methods: We retrospectively analyzed 238 patients with thoracic diseases who underwent thoracic surgery. We reviewed the rates of nasal carriage of MRSA and SSIs. Results: Results of MRSA screening were positive in 11 of 238 patients (4.6%), and 9 of these 11 patients received nasal mupirocin. SSIs occurred in 4 patients (1.8%). All 4 patients developed pneumonia; however, MRSA pneumonia occurred in only 1 of these 4 patients. No patient developed wound infection, empyema, and/or mediastinitis. SSIs did not occur in any of the 11 patients with positive results on MRSA screening. Conclusions: The rates of nasal carriage of MRSA and SSIs were low in this case series. Surveillance is important to determine the prevalence of MRSA carriage and infection in hospitals, particularly in the intensive care unit. However, routine preoperative screening for nasal carriage of MRSA is not recommended in patients undergoing general thoracic surgery.

Structural brain network analysis of children with localization-related epilepsy.

INTRODUCTION: Epilepsy is considered to arise from dysfunction in neural networks. Recent advances in neuroimaging and its analysis have made it possible to investigate both functional and structural connectivity in the brain. The aim of this study was to elucidate alterations in the structural connectivity in children with localization-related epilepsy using the mathematical method of graph theoretical analysis. METHODOLOGY: Fifteen children with localization-related epilepsy (8 female subjects; mean age, 8.5±3.5years) as an epilepsy group and 23 children without a history of seizure (12 female subjects; mean age, 8.9±3.7years) as a control group underwent three-dimensional T1-weighted brain magnetic resonance imaging (MRI). Gray matter images segmented and spatially normalized from the MRIs of both groups were analyzed using statistical parametric mapping with the Graph Analysis Toolbox. We compared global networks (global efficiency, clustering coefficient and network strength) and regional networks (betweenness centrality and clustering) between patients and controls. RESULTS: The global efficiency tended to be increased (p=0.081) and the global modularity was significantly increased (p=0.017) in the epilepsy group as compared with the control group. The epilepsy group showed locally decreased betweenness centrality mainly in the bilateral cingulate gyri, right perisylvian area, and bilateral precentral gyri, and locally increased clustering in the bilateral cingulate gyri, right perisylvian area, and medial frontal lobes as compared with the control group. The epilepsy group showed higher network resilience to random attack and targeted attack than the control group. Voxel-based morphometry did not show any difference between the two groups. CONCLUSIONS: We observed globally increased structural connectivity along with excessive network robustness in patients with localization-related epilepsy. Local abnormality of connectivity was observed mainly in the cingulate gyrus, perisylvian area, and precentral gyrus. This alteration in the structural connectivity without any morphometric changes may be related to the underlying epileptogenicity.

Propensity score-matching analysis of hybrid video-assisted thoracoscopic surgery and thoracoscopic lobectomy for clinical stage I lung cancer†.

OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) lobectomy is classified into hybrid VATS (direct and video vision) and thoracoscopic VATS (video vision only). In this study, the outcomes of hybrid VATS and thoracoscopic VATS for clinical stage I lung cancer were compared using a propensity score-matching analysis. METHODS: Hybrid and thoracoscopic VATS were performed in 178 and 76 patients, respectively. Propensity scores were calculated using logistic regression analysis and matched within a score of ±0.03 for age, sex, size of tumour, Charlson comorbidity index, preoperative therapy, percent vital capacity, forced expiratory volume in 1 s, clinical stage, pathological stage and histology. RESULTS: In the non-matched analysis, the results for hybrid and thoracoscopic VATS, respectively, were as follows: mean age, 69 ± 9 and 66 ± 10 years (P = 0.04); tumour size, 24 ± 10 and 20 ± 7 mm (P < 0.01); 2-deoxy-2 [F-18]fluorodeoxyglucose positron emission tomography SUV, 5.6 ± 4.4 and 3.6 ± 3.2 (P < 0.01); clinical stage (IA/IB), 130/48 and 69/7 (P < 0.01); pathological stage (IA/IB/IIA and IIB/IIIA and IIIB), 89/56/15/18 and 57/14/2/3 (P < 0.01); postoperative complications, 66 (37.1%) and 16 (21.1%; P = 0.01); respiratory complications, 32 (18.0%) and 6 (7.9%; P = 0.04); 5-year overall survival (OS), 77.0 and 88.8% (log-rank P = 0.045); and 5-year disease-free survival (DFS), 67.2 and 81.1% (log-rank P = 0.02). In 66 matched cases, the results for hybrid and thoracoscopic VATS, respectively, were as follows: mean operative time, 245 ± 96 and 285 ± 85 min (P = 0.01); blood loss, 95 ± 100 and 86 ± 123 ml (P = 0.67); mean duration of drainage, 3.6 ± 2.7 and 3.2 ± 2.2 days (P = 0.37); postoperative complications, 21 (31.8%) and 14 (21.2%; P = 0.17); respiratory complications, 11 (16.7%) and 5 (7.6%; P = 0.11); 5-year OS, 72.5 and 86.0% (log-rank P = 0.25); and 5-year DFS, 68.4 and 77.2% (log-rank P = 0.17). CONCLUSIONS: In this single-institution, propensity score-matched study, hybrid VATS showed a shorter operative time and similar outcomes compared with thoracoscopic lobectomy for clinical stage IA lung cancer.

Influence of smoking on perioperative oxidative stress after pulmonary resection.

PURPOSE: We herein investigated the influence of smoking on changes in the levels of perioperative oxidative stress after pulmonary resection. METHODS: A total of 31 patients with primary lung cancer who underwent curative pulmonary lobectomy were analyzed prospectively. The degree of perioperative oxidative stress was evaluated based on the serum levels of derivatives of reactive oxygen metabolites (d-ROM) and biological antioxidant potential (BAP). The patients were divided into two groups: group A (smoking < 40 pack-years) and group B (smoking ≥ 40 pack-years). The d-ROM and BAP measurements were obtained preoperatively, postoperatively and on the first, second, third and fifth postoperative days. RESULTS: In all 31 cases, the d-ROM values were higher on the third and fifth postoperative days than preoperatively. The extent of change in the d-ROM levels was greater in group A than in group B on the second, third and fifth postoperative days (1.05 ± 0.159 vs. 0.920 ± 0.205, p = 0.008; 1.20 ± 0.233 vs. 1.02 ± 0.186, p = 0.032; 1.34 ± 0.228 vs. 1.07 ± 0.200, p = 0.003, respectively). In contrast, there were no significant differences in the BAP values. The maximum increase in the d-ROM level and decrease in the BAP level negatively correlated with the amount of smoking (|r| = 0.428, p = 0.016 and |r| = 0.357. p = 0.049, respectively). CONCLUSIONS: Surgical stress associated with pulmonary lobectomy induces oxidative stress. In addition, smoking reduces the oxidative stress reaction, and the degree of this change is correlated with the amount of smoking.

ECHS1 mutations cause combined respiratory chain deficiency resulting in Leigh syndrome.

The human ECHS1 gene encodes the short-chain enoyl coenzyme A hydratase, the enzyme that catalyzes the second step of ß-oxidation of fatty acids in the mitochondrial matrix. We report on a boy with ECHS1 deficiency who was diagnosed with Leigh syndrome at 21 months of age. The patient presented with hypotonia, metabolic acidosis, and developmental delay. A combined respiratory chain deficiency was also observed. Targeted exome sequencing of 776 mitochondria-associated genes encoded by nuclear DNA identified compound heterozygous mutations in ECHS1. ECHS1 protein expression was severely depleted in the patient's skeletal muscle and patient-derived myoblasts; a marked decrease in enzyme activity was also evident in patient-derived myoblasts. Immortalized patient-derived myoblasts that expressed exogenous wild-type ECHS1 exhibited the recovery of the ECHS1 activity, indicating that the gene defect was pathogenic. Mitochondrial respiratory complex activity was also mostly restored in these cells, suggesting that there was an unidentified link between deficiency of ECHS1 and respiratory chain. Here, we describe the patient with ECHS1 deficiency; these findings will advance our understanding not only the pathology of mitochondrial fatty acid ß-oxidation disorders, but also the regulation of mitochondrial metabolism.

The evaluation of oxidative DNA damage in children with brain damage using 8-hydroxydeoxyguanosine levels.

Urinary and cerebrospinal fluid (CSF) levels of 8-hydroxydeoxyguanosine (8-OHdG) were examined to estimate the relevance of oxidative stress in children with brain damage. Urinary 8-OHdG levels were measured in 51 children with various forms of central nervous system (CNS) disorders (status epilepticus [SE], hypoxic-ischemic encephalopathy [HIE], CNS infections and chronic epilepsy) and these levels were compared with those in 51 healthy children. CSF 8-OHdG levels were measured in 25 children with brain damage and in 19 control subjects. In addition, urinary and CSF levels of 8-OHdG were compared between the children with brain damage and healthy children. Finally, the relationship between urinary and CSF levels of 8-OHdG was determined in 12 children that provided both urinary and CSF samples. Our results showed that urinary 8-OHdG levels in children with HIE and CNS infections were higher than those of controls (Steel test; p < 0.05 and p < 0.05, respectively) and that CSF 8-OHdG levels were higher in children with SE, HIE, and CNS infections than in control subjects (Steel test; p < 0.01, 0.05 and 0.05, respectively). In addition, a positive correlation between the levels of urinary and CSF 8-OHdG was noted in the 12 children that provided both CSF and urinary samples (Spearman's rank correlation; rho = 0.82, p < 0.01). Further, we observed changes in the urinary 8-OHdG in a patient with HHV-6 encephalopathy, and found that the changes correlated well with the patient's clinical condition. These results suggest that oxidative stress is strongly related to acute brain damage in children, and that 8-OHdG is a useful marker of brain damage. Therefore, repeated measurements of urinary 8-OHdG may be helpful in estimating the extent of brain damage.