Usefulness of the hybrid technique of interventional radiology and endoscopic treatment for intestinal bleeding after pancreaticoduodenectomy: a case report.

Introduction and importance: In endovascular treatment of ruptured pseudoaneurysm after pancreaticoduodenectomy (PD) with gastrointestinal bleeding, treatment for vasospasm of the culprit vessel from haemorrhagic shock and subsequent reperfusion has not been determined before. Case presentation: The authors hereby present you with a case of a 59-year-old man with unknown operative method upon arrival at the Emergecy room and who had hematemesis and collapse 6 months post-PD surgery. Clinical discussion: An initial contrast-enhanced computed tomography (CT) revealed no obvious source of bleeding, so an upper gastrointestinal endoscope was performed. Rebleeding occurred during the examination, and interventional radiology was performed because haemostasis was difficult. Coil embolization was performed for leakage of contrast material from the gastroduodenal artery stump into the gastrointestinal tract. However, because the embolization was uncertain due to vasospasm of the common hepatic artery, endoscopic clipping of the perforation site was also performed to prevent rebleeding due to reperfusion after improvement of vasospasm. A CT scan 5 days later showed reperfusion of the coil-implanted vessel. No rebleeding or hepatic infarction occurred postoperatively. Conclusion: In this case, the haemostasis by coil embolization was uncertain due to the presence of vasospasm, and clipping was used in combination with the procedure to prevent rebleeding.

Tympanic membrane findings and Eustachian tube function after transtympanic plugging for the chronic patulous Eustachian tube.

OBJECTIVE: To evaluate Eustachian tube (ET) function after Kobayashi plug surgery based on the tympanic membrane (TM) findings and active opening (AO) of the ET assessed with sonotubometry. SUBJECTS AND METHODS: A retrospective survey of medical records identified 74 ears of 66 patients with patulous ET (PET) received transtympanic insertion of the Kobayashi plug. Excluding the six ears (6 patients) with abnormal preoperative TM, sixty-eight ears of 60 patients were found to have normal TM preoperatively. Among these 68 ears, there were 51 ears in which sonotubometry was performed both before and after surgery to evaluate whether the AO of the ET was positive or not. RESULTS: Out of the 68 ears with normal preoperative TM, 52 ears (76.5%) were judged successful (sum of complete relief and significant improvement). The postoperative TM was normal in 41 ears (60.3%), while 27 ears (39.7%) had abnormal TM findings postoperatively. The success rate was 75.6% (31/41) in ears with normal postoperative TM, while it was 77.8% (21/27) in ears with abnormal TM. Success in maintaining normal postoperative TM was found in 45.6% (31/68) of the total ears treated. Out of the 51 ears in which sonotubometry was performed both before and after surgery, AO was preoperatively positive in 88.2% of the ears (45/51), while it was positive in 64.7% (33/51) postoperatively. In thirty-four ears with normal TM postoperatively, AO was positive in 24 ears (70.6%), while it was positive in 9 out of 17 ears (52.9%) with abnormal postoperative TM. The success rate was 70.6% (36/51) for the 51 ears in which AO was assessed both pre- and postoperatively, and it was 66.7% (22/33) in ears with positive AO postoperatively, while it was 77.8% (14/18) in ears without AO postoperatively. The incidence of ears either having normal postoperative TM or positive AO postoperatively was 84.3% (43/51). Abnormal postoperative TM findings without effectiveness were found in 8.8% (6/68). CONCLUSION: The obstructive dysfunction of the ET is a calculated risk but did not occur in most ears after plugging with the Kobayashi plug. Therefore, routine insertion of the VT at the same time as the initial surgery is not recommended for PET cases that are adequately followed up.

Familial Paget's disease of bone with ocular manifestations and a novel TNFRSF11A duplication variant (72dup27).

INTRODUCTION: Paget's disease of bone (PDB) is a skeletal disorder characterized by disorganized bone remodeling due to abnormal osteoclasts. Tumor necrosis factor receptor superfamily member 11A (TNFRSF11A) gene encodes the receptor activator of nuclear factor kappa B (RANK), which has a critical role in osteoclast function. There are five types of rare PDB and related osteolytic disorders due to TNFRSF11A tandem duplication variants so far, including familial expansile osteolysis (84dup18), expansile skeletal hyperphosphatasia (84dup15), early-onset familial PDB (77dup27), juvenile PDB (87dup15), and panostotic expansile bone disease (90dup12). MATERIALS AND METHODS: We reviewed a Japanese family with PDB, and performed whole-genome sequencing to identify a causative variant. RESULTS: This family had bone symptoms, hyperphosphatasia, hearing loss, tooth loss, and ocular manifestations such as angioid streaks or early-onset glaucoma. We identified a novel duplication variant of TNFRSF11A (72dup27). Angioid streaks were recognized in Juvenile Paget's disease due to loss-of-function variants in the gene TNFRSF11B, and thought to be specific for this disease. However, the novel recognition of angioid streaks in our family raised the possibility of occurrence even in bone disorders due to TNFRSF11A duplication variants and the association of RANKL-RANK signal pathway as the pathogenesis. Glaucoma has conversely not been reported in any case of Paget's disease. It is not certain whether glaucoma is coincidental or specific for PDB with 72dup27. CONCLUSION: Our new findings might suggest a broad spectrum of phenotypes in bone disorders with TNFRSF11A duplication variants.

Immunohistochemical localization of d-ß-aspartic acid in congenital and acquired middle ear cholesteatoma.

Objective/Hypothesis: Middle ear cholesteatoma is characterized by abnormal growth of the keratinizing squamous epithelium of the temporal bone. d-ß-aspartic acid is the major isomer of d-aspartic acid found in elderly tissue. We assessed the immunoreactivity to k-ß-aspartic acid of congenital and acquired middle ear cholesteatomas. Study Design: Case-control studies. Material and Methods: Tissue samples were collected from 21 patients comprising 21 ears with congenital middle ear cholesteatoma and 26 patients comprising 29 ears with acquired type. Their clinical and histopathological features were investigated. We divided the middle ear cholesteatoma samples into three layers: the perimatrix, matrix, and cystic contents. The patterns of immunoreactivity to d-ß-aspartic acid expression were then assessed immunohistochemically. Results: Two patterns of immunoreactivity to d-ß-aspartic acid were detected in middle ear cholesteatoma: infiltrative and diffuse. In congenital middle ear cholesteatoma, d-ß-aspartic acid expression was observed throughout all the layers (perimatrix, matrix, and cystic contents), and immunoreactivity to d-ß-aspartic acid was dramatically strong in all layers. The expression levels of d-ß-aspartic acid to the cystic content and perimatrix were significantly higher in congenital middle ear cholesteatoma than in the acquired type. Conclusions: This study showed the expression levels of d-ß-aspartic acid in middle ear cholesteatoma to differ significantly between congenital and acquired middle ear cholesteatoma. Our results indicate that overexpression of d-ß-aspartic acid is likely to be involved in the pathogenesis of cholesteatoma, and we speculate that d-ß-aspartic acid could be a novel biomarker for, and a therapeutic target in, congenital and acquired middle ear cholesteatoma. Level of Evidence: 4.

Outcome of the 'waiting until spontaneous extrusion' strategy for long-term tympanostomy tube placement in children with cleft palate.

BACKGROUND: Otitis media with effusion (OME) in children with cleft palate (CP) is known to be refractory to treatment and most of these patients undergo surgery for ventilation tube (VT) placement. OBJECTIVES: To identify the outcomes of children with CP using long-term VT with a 'waiting until spontaneous extrusion' strategy. MATERIAL AND METHODS: We retrospectively reviewed the medical records of all children with CP who visited our department from December 2016 to November 2017 and who received long-term VT placement in our department. Risk factors related to residual perforation and recurrence of OME were analyzed. RESULTS: A total of 106 children were included in this study. Our statistical analysis of 94 ears followed for more than three months after VT loss revealed that longer VT placement was associated with residual perforation, and shorter VT placement was associated with OME recurrence. Although a longer duration of VT placement was associated with an increased rate, extremely long-term VT placement was not associated with residual perforation, as expected. Half of the VTs were spontaneously extruded at 40 months after insertion. CONCLUSIONS AND SIGNIFICANCE: Long-term VT insertion using a waiting until spontaneous extrusion strategy is a potential option for children with CP.

N100m latency shortening caused by selective attention.

The N100m response to a specific same-sound stimulus may be altered by the degree of attention paid to the stimulus. When participants selectively pay attention to the stimulus, the N100m amplitude increases; however, minimal effects are observed on the N100m latency. In this study, we examined the effects of selective special attention (motivation) to extract the frequency (or pitch) information from a probe tone on the N100m response to the probe tone. We compared the N100m latencies and amplitudes using magnetoencephalography, with the following three experimental conditions: 1) vocalization task protocol (vocalize in tune with the pitch of the probe tone after the presentation of the probe tone), 2) hearing task protocol (just listen to the probe tone), and 3) imagining (just imagine the vocalization in tune with the probe tone). The results indicated that the N100m latency in response to the probe tone was significantly shortened in the vocalization and imagining tasks compared with the hearing task in the right hemisphere of the brain. The amplitude was significantly increased in the vocalization task compared with the imagining and hearing tasks in the right hemisphere, and in the vocalization task compared with the hearing task in the left hemisphere of the brain; that is, the attention and/or motivation required to extract the information from the stimulus tones may have caused N100m latency shortening. To our knowledge, this study is the first to demonstrate that the N100m latency may be shortened under particular attentional conditions in response to a simple tone.

The size of palatine tonsils cannot be used to decide the indication of tonsillectomy for IgA nephropathy.

Background. Tonsillectomy is one of the treatment strategies for immunoglobulin A nephropathy (IgAN). The relationship between the indication of tonsillectomy and the size of palatine tonsils (PTs) in patients with IgAN remains controversial. Methods. This retrospective cohort study investigated 57 patients with IgAN who underwent tonsillectomy combined with steroid pulse therapy (SPT). They were classified into two groups, the hypertrophy group and the nonhypertrophy group, according to the weight of their excised PTs. The effects of tonsillectomy combined with SPT on clinical remission (CR) and the histopathological findings of PTs were compared between the two groups. Results. During the mean follow-up period of 45.5 (range 6-133) months, 78.9% of the patients achieved CR (79.3 versus 78.6%, P = 0.945) and the baseline serum creatinine doubled only in one patient in the nonhypertrophy group (0 versus 3.6%, P = 0.491). No significant difference was observed in the incidence of CR between the two groups by the Kaplan-Meier method (P = 0.839). The predictor for CR, identified in Cox proportional hazards models, was baseline proteinuria [hazard ratio 0.14 (95% CI 0.032-0.621) P = 0.010]. Although macroscopic pus plugs were observed on the surface of PTs in almost 60% of patients in each group, microscopic pus plugs in the crypt and the enlarged interfollicular area were observed in all patients. Conclusions. The treatment effect of tonsillectomy combined with SPT and the pathological features of PTs in IgAN were equal, regardless of the size of the PTs. Therefore, the size of PTs should not be included as a factor when deciding the indication of tonsillectomy for IgAN.

Minimally Invasive Treatment for Hard Palate-Invading Maxillary Keratocystic Odontogenic Tumor.

Keratocystic odontogenic tumor (KCOT) is one of the benign developmental odontogenic cystic lesions arising from impacted teeth. In comparison to other odontogenic cysts, such as radicular cysts and dentigerous cysts, KCOT is known to be more aggressive and is associated with a relatively high recurrence rate. Traditionally, KCOT has been treated with total resection through sublabial incision. Marsupialization is advocated to reduce surgical invasion. However in all the cases, marsupialization was performed in the oral cavity. With the recent development of appropriate instruments and the endoscopic modified medial maxillectomy (EMMM) technique, which allows preservation of the inferior turbinate and nasolacrimal duct, an exclusive endoscopic approach to KCOT becomes possible. However, when the KCOT invades the hard palate, total resection of the tumor requires subtotal maxillectomy including hard palate. Consequently, as the maxillary sinus connects to the oral cavity, life-long use of a prosthesis becomes mandatory. Here we report a case of a seventeen-year-old female with a hard palate-invading KCOT who was successfully treated with the EMMM approach. The KCOT was fenestrated to the nasal cavity, leading to preservation of the hard palate. The lesion invading the hard palate was found to remain unchanged over one year upon follow-up. The trans-nasal approach with EMMM is a direct, minimally invasive method providing a direct field of view for the treatment of maxillary odontogenic cysts. Marsupialization of the KCOT with the EMMM technique might be a viable treatment option if the maxillary KCOT invades surrounding structures.

Clinical factors indicating short nasal bone overlap.

CONCLUSION: It is important to take adequate precautions when performing septoplasty for elderly patients. OBJECTIVE: Septoplasty is the treatment of choice for deviation of the nasal septum. Saddle nose is a rare complication caused by damage to the keystone area. In this area, the nasal bone overlaps the upper lateral cartilages, so careful attention is needed when performing septoplasty to patients with short nasal bone overlap. Therefore, the factors associated with short nasal bone overlap were investigated to allow adequate precautions to be taken during surgery. METHOD: Computed tomography (CT) including the paranasal sinus region was performed in 177 patients. Data including sex, age, and the primary disease were obtained from their medical records. The degree of septal deviation and the bone overlap distance in the midline were measured using CT. RESULT: It was found that advancing age was significantly associated with shorter bone overlap distance in the midline. There was no significant association between the degree of septal deviation and nasal bone overlap distance in the midline. Furthermore, there was no significant difference in the overlap distance between nasal sinus diseases and other diseases, and between sexes.

Esquistossomose mansônica em Carajás, Pará, Brasil: estudo retrospectivo realizado no Hospital Yutaka Takeda / Schistosomiasis mansoni in Carajás, Pará, Brazil: retrospective study carried out in the Yutaka Takeda hospital

A esquistossomose mansônica é uma endemia que avança acompanhando os processos migratórios da população e se instala de acordo com as condições epidemiológicas e ambientais favoráveis. Neste sentido, realizou-se um trabalho no município de Parauapebas, área de intensa migração no sudeste do Pará, onde prevalece a extração de minérios, com a proposta de avaliar a possibilidade da existência de transmissão ativa de esquistossomose. Foi traçado o perfil epidemiológico dos pacientes com esquistossomose atendidos no Hospital Yutaka Takeda em Carajás, no período 2004-2005. O estudo resultou do levantamento de dados em fichas de notificação, em prontuários do paciente e de investigação epidemiológica. Dados complementares foram obtidos mediante estudo prospectivo com aplicação de questionário em pacientes e familiares. Realizou-se investigação epidemiológica em 20 indivíduos, todos procedentes de regiões endêmicas ou de áreas focais. Não foi detectado nenhum caso que sugerisse autoctonia. Noventa e cinco por cento dos pacientes são do gênero masculino, idade média de 27 anos e trabalham para empresas que prestam serviços em atividades ligadas à mineração. Considerando-se a constante migração para a região, conclui-se a necessidade de estudo amplo de controle da esquistossomose e adoção de medidas preventivas, como a educação em saúde.

[A case report of inflammatory pseudotumor of the urinary bladder due to diverticulitis of the sigmoid colon].

A 65-year-old female presented to our hospital with a 6-month history of pollakuria, low-grade fever and urgent incontinence. Cystoscopy revealed a nonpapillary bladder tumor that was 50 mm in diameter in the trigon. Computed tomography showed the abscess between the urinary bladder and sigmoid colon. Transurethral resection was performed and the histology consisted of inflammatory lesions with inflammatory cell infiltration, which was diagnosed as an inflammatory pseudotumor due to diverticulitis of the sigmoid colon. Sigmoidectomy was subsequently performed. A fistula between the urinary bladder and the sigmoid colon was not detected. Cystoscopy 2 months after the operation revealed no signs of a bladder tumor.

Polymerase chain reaction-based subtyping of ureaplasma parvum and ureaplasma urealyticum in first-pass urine samples from men with or without urethritis.

BACKGROUND: Our previous study suggested a significant association between Ureaplasma urealyticum and nongonococcal urethritis (NGU). However, association of the serovars of U. urealyticum with NGU remains unclear. A polymerase chain reaction (PCR)-based assay can distinguish 4 serovars of Ureaplasma parvum from each other and categorize 10 serovars of U. urealyticum into 3 subtypes: subtype 1 (serovars 2, 5, 8, and 9), subtype 2 (serovars 4, 10, 12, and 13), and subtype 3 (serovars 7 and 11). GOAL: The goal of this study was to determine which subtypes of U. urealyticum are associated with NGU as determined by PCR-based assay. STUDY: The prevalence of U. urealyticum subtypes in 106 ureaplasma-positive men with urethritis was compared with that in 30 ureaplasma-positive men without urethritis. RESULTS: : In men with nonchlamydial NGU and men with Mycoplasma genitalium-negative nonchlamydial NGU, only U. urealyticum subtype 1 (serovars 2, 5, 8, and 9) was detected significantly more often than in men without urethritis. CONCLUSION: This study suggests that subtype 1 of U. urealyticum (serovars 2, 5, 8, and 9) is associated with NGU independently of Chlamydia trachomatis or M. genitalium.

[Four cases of idiopathic retroperitoneal fibrosis markedly responsive to steroid therapy].

We report four cases of idiopathic retroperitoneal fibrosis (IRPF) effectively treated with steroid therapy. Computed tomographic (CT) scan showed the density of soft tissue mass enveloping the abdominal aorta in four cases. From radiographic findings we made a diagnosis of IRPF. Management with steroid therapy over three months improved general symptoms and radiographic findings. Prominent calcification in the wall of the abdominal aorta indicated that the arteriosclerosis was related to IRPF. We measured serum antibodies for Chlamydia pneumoniae in four cases.