A novel radiological assessment to identify acute vertebral compression fractures: A pilot observational study.

Aim: The diagnosis of acute vertebral compression fractures (AVCFs) is often challenging. An alternative to magnetic resonance imaging, which may not always be available, includes a comparison of supine and sitting/standing position radiographs. However, this cannot be accomplished in patients with acute vertebral compression fractures who require emergency transport and are in severe pain. In this study, aimed to assess the diagnostic accuracy of comparing lateral-view radiographs of the thoracolumbar spine in supine and 30° head-elevated positions, which are less painful. Methods: We retrospectively examined 30 patients with AVCFs who were transported by ambulance to our emergency department between June 2018 and May 2019. All underwent 30° head-elevated lateral-view thoracolumbar spine radiography and magnetic resonance imaging. We evaluated vertebral fractures by examining changes in vertebral wedging ratio (WR) from supine to 30° head-elevated position (Δ WR) using the following equation: Δ WR = WR (30° head-elevated) - WR (supine). We compared Δ WR to that of unfractured vertebrae as control. Results: A total of 176 vertebrae were included (fractured, 32 and non-fractured, 144). Δ WR of fractured vertebrae ranged between 5.1% and 24.4%, whereas non-fractured vertebrae ranged between -6.7% and 4.3%. Median Δ WR of fractured vertebrae was significantly higher than non-fractured vertebrae (12.6% versus -0.5%, p < 0.001). No patients reported pain during 30° head-elevated positioning. Conclusions: Lateral radiographs in supine and 30° head-elevated positions can accurately diagnose of AVCF, without worsening pain. This study showed a Δ WR value of ≥5.1% for AVCFs.

Intensive care management of a patient with necrotizing fasciitis due to non-O1/O139 Vibrio cholerae after traveling to Taiwan: a case report.

BACKGROUND: Vibrio cholerae are oxidase-positive bacteria that are classified into various serotypes based on the O surface antigen. V. cholerae serotypes are divided into two main groups: the O1 and O139 group and the non-O1/non-O139 group. O1 and O139 V. cholerae are related to cholera infection, whereas non-O1/non-O139 V. cholerae (NOVC) can cause cholera-like diarrhea. A PubMed search revealed that only 16 cases of necrotizing fasciitis caused by NOVC have been recorded in the scientific literature to date. We report the case of a Japanese woman who developed necrotizing fasciitis caused by NOVC after traveling to Taiwan and returning to Japan. CASE PRESENTATION: A 63-year-old woman visited our hospital because she had experienced left knee pain for the past 3 days. She had a history of colon cancer (Stage IV: T3N3 M1a) and had received chemotherapy. She had visited Taiwan 5 days previously, where she had received a massage. She was diagnosed with septic shock owing to necrotizing fasciitis. She underwent fasciotomy and received intensive care. She recovered from the septic shock; however, after 3 weeks, she required an above-knee amputation for necrosis and infection. Her condition improved, and she was discharged after 22 weeks in the hospital. CONCLUSIONS: With the increase in tourism, it is important for clinicians to check patients' travel history. Clinicians should be alert to the possibility of necrotizing fasciitis in patients with risk factors. Necrotizing fasciitis caused by NOVC is severe and requires early fasciotomy and debridement followed by intensive postoperative care.

Evaluation of the 5-fluorouracil plasma level in patients with colorectal cancer undergoing continuous infusion chemotherapy.

5-Fluorouracil (5-FU) dosing has traditionally been based on the body surface area (BSA) in colorectal cancer treatment. However, there is accumulating evidence that dosing based on BSA may be of limited use. The purpose of the present study was to evaluate the changes in 5-FU plasma levels and tumor response as well as the severity of adverse events in patients with cancer treated with 5-FU combined chemotherapy. The dosing amount of 5-FU was determined based on the BSA. Blood samples were collected, and 5-FU plasma levels in 15 patients with colorectal cancer were measured three times (0, 22 and 40 h before and after the start of infusion) during constant-infusion of 5-FU for 46 h by an immunoassay. 5-FU plasma levels were significantly higher at 22 and 40 h compared with at 0 h (P<0.001), when all 15 patients were analyzed. Notably, the tumor response of the partial response/stable disease group showed significant increases in 5-FU plasma levels at 40 h compared with at 22 h (P<0.01), while the progressive disease group showed no significant increase. In addition, the 5-FU plasma level in the adverse event level of grade ≥2 was higher than that of grade <2 at 40 h after the start of infusion. Collectively, these observations indicated that during continuous infusion of 5-FU, the 5-FU plasma level increased significantly, and the tumor response (such as partial response, stable or progressive disease) may be influenced by the increase of 5-FU plasma level from the start of infusion. Therefore, the 5-FU plasma level may be a predictive factor for maximizing the tumor response and minimizing the risk of severe adverse events.

Impact of primary tumor location as a predictive factor in patients suffering from colorectal cancer treated with cytotoxic anticancer agents based on the collagen gel droplet-embedded drug sensitivity test.

In recent studies, better clinical outcomes for patients with left-sided colon cancer (CC) compared with right-sided CC have been reported; however, in such investigations, the chemotherapy regimens included molecular-targeting agents. To the best of our knowledge, the impact of primary tumor location as a predictive factor in patients suffering from CC treated with cytotoxic anticancer agents alone has not been investigated. The aim of the present study was to determine the impact of the primary tumor location as a predictive factor of patients undergoing the following cytotoxic anticancer agent regimens: Leucovorin and fluorouracil + oxaliplatin (FOLFOX) or Leucovorin and fluorouracil + irinotecan (FOLFIRI), using the collagen gel droplet-embedded drug sensitivity test (CD-DST). Between March 2008 and April 2017, tumor specimens were obtained from 133 patients suffering from colorectal cancer (CRC) who had not received preoperative chemotherapy. CD-DST was performed and the growth inhibition rate (IR) was determined in FOLFOX and FOLFIRI regimens. The associations between tumor location and IR values for each condition were evaluated. In the present study, the prognosis of patients receiving palliative chemotherapy as well as treatment with molecularly-targeted agents was also investigated. There were no significant differences in the IRs (%) of the two regimens using CD-DST for right-sided tumors compared with left-sided tumors, including or excluding the rectum. The median survival times of patients with right CC and left CC who had received palliative chemotherapy and treatment with molecularly-targeted agents were 960 and 1,348 days, respectively. Primary tumor location did not represent a predictive factor for the efficacy of treatment with cytotoxic anticancer agent regimens using CD-DST. However, patients suffering from left-sided CC were revealed to exhibit better clinical outcomes compared with patients suffering from right-sided CC when molecularly-targeted agent regimens were administered. Therefore, the results of the present study suggested that molecularly-targeted agents rather than cytotoxic anticancer agents may result in improved clinical outcomes for patients with CRC suffering from left-sided tumors.

Outcomes after Traumatic Brain Injury with Concomitant Severe Extracranial Injuries.

Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. Patients with TBI frequently sustain concomitant injuries in extracranial regions. The effect of severe extracranial injury (SEI) on the outcome of TBI is controversial. For 8 years, we retrospectively enrolled 485 patients with the blunt head injury with head abbreviated injury scale (AIS) ≧ 3. SEI was defined as AIS ≧ 3 injuries in the face, chest, abdomen, and pelvis/extremities. Vital signs and coagulation parameter values were also extracted from the database. Total patients were dichotomized into isolated TBI (n = 343) and TBI associated with SEI (n = 142). The differences in severity and outcome between these two groups were analyzed. To assess the relation between outcome and any variables showing significant differences in univariate analysis, we included the parameters in univariable and multivariable logistic regression analyses. Mortality was 17.8% in the isolated TBI group and 21.8% in TBI with SEI group (P = 0.38), but the Glasgow Outcome Scale (GOS) in the TBI with SEI group was unfavorable compared to the isolated TBI group (P = 0.002). Patients with SBP ≦ 90 mmHg were frequent in the TBI with SEI group. Adjusting for age, GCS, and length of hospital stay, SEI was a strong prognostic factor for mortality with adjusted ORs of 2.30. Hypotension and coagulopathy caused by SEI are considerable factors underlying the secondary insults to TBI. It is important to manage not only the brain but the whole body in the treatment of TBI patients with SEI.

Comparison of Postoperative Pain in Patients Following Transcanal Endoscopic Versus Microscopic Ear Surgery.

OBJECTIVE: To compare levels and causes of postoperative pain after cholesteatoma removal by transcanal endoscopic ear surgery (TEES) versus microscopic ear surgery (MES). STUDY DESIGN: Prospective case series. SETTING: Tertiary referral center. PATIENTS: One-hundred-and-sixty-one patients who had undergone middle ear surgery between February 2013 and April 2016. INTERVENTIONS: Comparison of postoperative pain between TEES and MES groups and among TEES and MES subgroups divided by range of bone removal. MAIN OUTCOME MEASURES: Two parameters were used to assess postoperative pain: a pain numeric rating scale (NRS) and number of times a non-steroidal anti-inflammatory drug (NSAID) was taken from postoperative days (PODs) 1 to 7. We also examined the primary factor behind postoperative pain looking at: 1) the surgical incision; 2) bone removal; and 3) number of involved middle ear regions. RESULTS: One-hundred-and-six patients underwent TEES and 55 underwent MES. The mean pain NRS for the 7-day postoperative period was significantly lower for the TEES group (1.1) than the MES group (2.8) (p < 0.001, Mann-Whitney U test). The number of times a NSAID was taken was lower for the TEES group (1.3 pills/wk) than the MES group (5.5 pills/wk) (p < 0.001, Mann-Whitney U test). The mean pain NRS of the TEES and MES subgroups also suggests that extent of bone removal or number of involved middle regions was less important in causing postoperative pain than presence or absence of the retroauricular incision. CONCLUSIONS: TEES is associated with lower postoperative pain and lower use of NSAIDs compared with MES patients.

Impact of the individualization of the first-line chemotherapy for advanced colorectal cancer based on collagen gel droplet-embedded drug sensitivity test.

Leucovorin (FOL) and fluorouracil (5-FU) plus oxaliplatin (l-OHP; FOLFOX) or FOL and 5-FU plus irinotecan (SN-38; FOLFIRI) are widely used as first-line chemotherapy regimens in the treatment of advanced colorectal cancer (CRC). However, second-line chemotherapy must be abandoned in certain cases due to disease progression, adverse effects or high medical cost. Therefore, the most effective regimen should be selected as first-line chemotherapy. We reported that individualization of first-line treatment (FOLFOX/FOLFIRI/Dual/Poor responder) was possible using the collagen gel droplet-embedded culture drug sensitivity test (CD-DST) and that individualized first-line chemotherapy with CD-DST may improve the prognosis of patients with unresectable CRC. The aim of the present prospective cohort study was to evaluate the individualization of first-line chemotherapy using CD-DST, with a focus on prognosis. Between March 2008 and December 2015, tumor specimens were obtained from 120 patients with CRC who had not received preoperative chemotherapy. CD-DST was performed and the growth inhibition rate (IR) was determined by exposure for 24 h with 5-FU and l-OHP (6.0 and 3.0 µg/ml, respectively) and 5-FU and SN-38 (6.0 and 0.2 µg/ml, respectively). The cumulative distribution of IR values under each condition was evaluated on the basis that the clinical response to FOLFOX and FOLFIRI is equivalent (~50%). The prognosis of dual responder was improved compared with that of poor responders, however this difference was identified to be significant. There was no different prognosis between patients treated with an appropriate first-line regimen and patients treated with an inappropriate first-line regimen in dual responders. However, in poor responders, there were significant differences of prognosis between patients treated with an appropriate first-line regimen and patients treated with an inappropriate first-line regimen (P=0.036). In conclusion, the results from the present study suggest that administration of the recommended first-line regimen using CD-DST for patients with unresectable CRC is important for the improvement of prognosis, particularly in poor responders.

Acute septic arthritis of the temporomandibular joint derived from otitis media: a report and review of the English and Japanese literature.

Septic arthritis of the temporomandibular joint (SATMJ) is an extremely rare disease with characteristic features of preauricular pain, swelling, redness, and malocclusion. The present report describes a case of SATMJ derived from otitis media, which resulted in a good outcome. We also reviewed the English and Japanese literature with special interest in etiology. It is generally agreed that contiguous or distant infection and trauma are common etiological factors of SATMJ. So far, these etiological factors are mainly discussed based on hypotheses rather than sufficient evidence. Therefore, in many past cases, accurate causes were not identified. To our knowledge, our case is the third report of SATMJ following otitis media. In addition, this is the first case in which the pathogenic bacterium responsible for the otitis media was the definite cause of the SATMJ. Cases of SATMJ are sometimes misdiagnosed with otitis media, and SATMJ derived from otitis media is extremely rare. Dentists and otolaryngologists should collaborate for the management of this disease as needed.

Safety of heat generated by endoscope light sources in simulated transcanal endoscopic ear surgery.

OBJECTIVE: To determine whether heat generated by endoscope light sources during ear surgery is safe. METHODS: Transcanal endoscopic ear surgery (TEES) was simulated using 2.7-mm or 4-mm endoscopes coupled to xenon or LED light sources and a 3D model of human temporal bone. The endoscope tip was fixed at the center of tympanic annulus. Light sources were tested at clinical (30% for xenon and 40% for LED) and 100% settings. Temperatures were measured using thermocouples attached to the endoscope tip and three points within the middle ear cavity: promontory, horizontal portion of the facial nerve and lateral semicircular canal. RESULTS: Maximum temperatures measured within the middle ear cavity were below 31°C at clinical settings, while the temperatures rose to 44.1°C using a 4-mm endoscope with a xenon light source set at 100%. Temperatures measured at the tip were all safe at clinical settings, but rose dramatically to 110.1°C for the 4-mm endoscope with xenon at 100%. CONCLUSION: Endoscopes can be safely used within the middle ear at clinical settings. However, operators should not exceed clinical settings, particularly with 4-mm endoscopes with a xenon light source, to ensure temperatures generated within the middle ear cavity are safe.

Severe heatstroke complicated with Takotsubo cardiomyopathy.

Case: A 69 year-old female with history of schizophrenia was transported to our hospital by ambulance due to coma. On arrival, she was hypotensive and tachycardic with a Glasgow coma scale score of 3 and a rectal core temperature of 40°C. Heatstroke was strongly suspected as the cause of the coma and hypotension. Active external cooling with an electric fan and cooled IV fluid administration were started. Her electrocardiogram (EKG) showed ST elevation in V2-6, II, III and aVF. Echocardiography revealed apical ballooning, which indicated Takotsubo cardiomyopathy. Coronary angiography indicated normal coronary arteries. Outcome: After admission to the intensive care unit, her cardiovascular status gradually improved and she was transferred to the psychiatric ward on day 36. Conclusion: Heatstroke and Takotsubo cardiomyopathy can share the same pathophysiology. Close evaluation of hemodynamic status and myocardial damage is critical for survival.

Transcanal endoscopic ear surgery for pediatric population with a narrow external auditory canal.

OBJECTIVES: To retrospectively determine the size of the external auditory canal (EAC) in a pediatric population and to describe our experience with transcanal endoscopic ear surgery (TEES) in this pediatric population which had been successfully treated for middle ear disease using TEES. METHODS: We analyzed 31 patients ranging in age from 2 to 13 years old (median: 7.6 years) with middle ear disease who underwent TEES between November 2011 and August 2014. Sixteen of these patients had surgery for cholesteatomas; 11 for chronic otitis media; and 4 for malformation of the middle ear. A preoperative CT scan was performed to evaluate the middle ear disease. Transcanal endoscopic tympanoplasty was performed using a rigid endoscope with a 2.7mm outer diameter. Transcanal endoscopic atticoantrotomy was also performed, as necessary, on some patients to access pathologies in the antrum. The values of anterior-posterior diameters and superior-inferior diameters of the bony parts of EAC were measured retrospectively based on the preoperative CT scan data. RESULTS: TEES was successfully performed in all 31 pediatric patients without resorting to a retroauricular incision. Twenty-seven patients were evaluated for postoperative hearing levels which were found to fall within an acceptable range and for postoperative air-bone gap (ABG) by pure tone audiometry with a resulting mean of 8.6dB. The smallest anterior-posterior diameters of the external ear canal ranged from 3.2 to 7.1mm (5.0±1.0mm) and the smallest superior-inferior diameters ranged from 3.4 to 10.3mm (5.9±1.3mm). CONCLUSION: TEES can be used to safely and effectively treat middle ear disease even in the pediatric population in its narrow EAC.

A case of meningococcal meningitis with multiple cerebellar microbleeds detected by susceptibility-weighted imaging.

BACKGROUND: Bacterial meningitis is a fatal infectious disease of the central nervous system complicating intravascular involvements. Multiple microbleeds are rarely identified as complications because of the limited detection threshold of conventional imaging modalities. We report the first case of meningococcal meningitis with successful identification of multiple microbleeds in the cerebellum by susceptibility-weighted imaging. CASE PRESENTATION: A 19-year-old Japanese female was brought to our emergency department because of fever and coma. A spinal tap was performed and turbid yellow fluid was collected. A diagnosis of bacterial meningitis was established and the patient was admitted to an intensive care unit. Dexamethasone and Antibiotics were administered and Neisseria meningitides was cultured from the spinal fluid. On day 10, postcontrast magnetic resonance imaging identified enhanced subarachnoid space in the cerebellum. Susceptibility-weighted imaging showed spotty low-intensity signals in the cerebellar tissue, indicating microbleeds. The patient made a full recovery from coma and was discharged without neurological sequelae on day 24. CONCLUSION: Meningococcal meningitis can cause multiple microbleeds in the cerebellum. In this report, we successfully identified microbleeds by susceptibility-weighed imaging. Using this imaging modality, further investigations will clarify its clinical incidence and significance.

The Efficacy of Color-Mapped Diffusion-Weighted Images Combined With CT in the Diagnosis and Treatment of Cholesteatoma Using Transcanal Endoscopic Ear Surgery.

OBJECTIVE: To assess the efficacy of a color-mapped diffusion-weighted image combined with a computed tomography scan (CMDWI-CT) in preoperatively evaluating the anatomical location of cholesteatomas and determining whether a patient is indicated for transcanal endoscopic ear surgery (TEES) to reduce intraoperative switching to microscopic ear surgery (MES). STUDY DESIGN: Prospective case study. SETTING: A single university hospital. PATIENTS: Fifty-five patients scheduled for middle ear cholesteatoma surgery. INTERVENTION: The CMDWI-CT is produced in a multistep process. A color-mapped fusion image (CMFI) is created by performing MR cisternography on a 1-mm thin-slice nonecho planar diffusion-weighted imaging (non-EPI DWI) and then by performing color mapping on the resulting image to enhance cholesteatoma visualization. False positives are reduced by taking a T1-weighted image (T1WI), whereas false negatives are further reduced by preoperative endoscopic examination. As cholesteatomas are difficult to locate on a CMFI in the temporal bone region, we stripped out the MR cisternography data from the CMFI and then fused the CMFI to the initial computer tomography (CT) scan to create a CMDWI-CT. This CMDWI-CT better clarifies the cholesteatoma position within temporal bone. MAIN OUTCOME MEASURE(S): CMDWI-CT preoperative findings were compared with intraoperative findings. The positive predictive value and negative predictive value were also evaluated depending on the cholesteatoma location. RESULTS: CMDWI-CT facilitated accurate detection of the cholesteatoma anatomical location in the temporal bone region which was reflected in positive predictive and negative predictive values of over 90% for all areas of the middle ear. CONCLUSION: CMDWI-CT is a reliable diagnostic modality for evaluating the anatomical location of cholesteatomas that seem as high-signal regions on a CMFI and for determining whether TEES is indicated for treatment in such patients.

Detectability and anatomical correlation of middle ear cholesteatoma using fused thin slice non-echo planar imaging diffusion-weighted image and magnetic resonance cisternography (FTS-nEPID).

Cholesteatomas show high intensity in diffusion-weighted imaging (DWI). We performed fused thin slice non-echo planar imaging (EPI) DWI and magnetic resonance cisternography (FTS-nEPID) for cholesteatoma patients to increase the detectability of FTS-nEPID for cholesteatoma. The subjects are 77 consecutive patients who underwent FTS-nEPID as a preoperative study (mean age: 53.3±21.8, 47 men and 30 women). Otorhinolaryngologists performed the operations. We anatomically classified the middle ear into four portions. A radiologist evaluated the images for cholesteatoma and assessed the anatomical invasive range in four portions using only FTS-nEPID. We classified large cholesteatomas that invaded more than three portions and small ones that invaded less than two portions based on the results obtained from surgery, and calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). For all cholesteatomas with an existing diagnosis, the sensitivity, specificity, PPV, and NPV were 71%, 70%, 94%, and 27%, respectively. In anatomical evaluation, the sensitivity, specificity, PPV, and NPV were 49%, 85%, 77%, and 64%, respectively. For large cholesteatomas with an existing diagnosis, the sensitivity was 86%. In anatomical evaluation, the sensitivity, specificity, PPV, and NPV were 51%, 57%, 88%, and 18%, respectively. For small cholesteatomas with an existing diagnosis, the sensitivity, specificity, PPV, and NPV were 59%, 78%, 92%, and 30%, respectively. In anatomical evaluation, the sensitivity, specificity, PPV, and NPV were 40%, 85%, 60%, and 71%, respectively. FTS-nEPID may be useful for diagnosing cholesteatomas. Further research is needed for anatomical evaluation because there were many false-negative results.

Mutations in the MYO15A gene are a significant cause of nonsyndromic hearing loss: massively parallel DNA sequencing-based analysis.

OBJECTIVES: Screening for MYO15A mutations was carried out using a large cohort to clarify the frequency and clinical characteristics of patients with MYO15A (DFNB3) mutations in a hearing loss population. METHODS: Genetic analysis of 63 previously reported deafness genes based on massively parallel DNA sequencing (MPS) in 1120 Japanese hearing loss patients from 53 otorhinolaryngology departments was performed. Detailed clinical features of the patients with MYO15A mutations were then collected and analyzed. RESULTS: Eleven patients from 10 families were found to have compound heterozygosity for MYO15A. Audiograms showed profound or high frequency hearing loss, with some patients showing progressive hearing loss. Age at onset was found to vary from 0 to 14 years, which seemed to be associated with the mutation. Four children underwent bilateral cochlear implantation for congenital hearing loss, with all showing good results. CONCLUSION: Mutations in the MYO15A gene are a notable cause of nonsyndromic hearing loss. MPS technology successfully detected mutations in relatively rare deafness genes such as MYO15A.

The efficacy of color mapped fusion images in the diagnosis and treatment of cholesteatoma using transcanal endoscopic ear surgery.

OBJECTIVE: To assess the efficacy of color mapped fusion images (CMFIs) in preoperatively evaluating the anatomic location of cholesteatomas and determining whether a patient is indicated for transcanal endoscopic ear surgery. STUDY DESIGN: Prospective case study. SETTING: A single university hospital. PATIENTS: Ninety-two patients scheduled for middle ear cholesteatoma surgery. INTERVENTION: Imaging analysis was first performed using echo planar diffusion-weighted imaging (EPI) for the first patient group with mixed results. Imaging analysis was then performed using 1-mm thin-slice non-EPI combined with magnetic resonance cisternography in a second group. The resulting image was then processed using color mapping to create a CMFI that enhanced cholesteatoma visualization. A second non-EPI was also performed on the third group, incorporating a T1-weighted image (T1WI) to reduce false-positives. MAIN OUTCOME MEASURE(S): Preoperative findings from EPI, non-EPI/CMFIs, and non-EPI/T1WI-enhanced CMFIs were compared with intraoperative findings. The positive predictive value and negative predictive value were also evaluated for each group. RESULTS: Both the positive predictive value and negative predictive value obtained from the CMFIs were high in all areas of the middle ear, and CMFI facilitated accurate detection of the anatomic location of cholesteatomas of 3 mm or larger. The incidence of false-positives was further reduced in the final 18 patients by performing T1WI to distinguish between cholesteatomas and cholesterin granulomas. CONCLUSION: CMFI combined with T1WI is a reliable diagnostic modality for evaluating the anatomic location of cholesteatomas 3 mm or larger and determining whether transcanal endoscopic ear surgery is indicated for treatment in such cases.

Mechanism underlying the transient increase of serum iron during FOLFOX/FOLFIRI therapy.

In patients with advanced colorectal cancer (CRC), a transient significant increase of serum iron is observed during chemotherapy with leucovorin and fluorouracil plus oxaliplatin (FOLFOX) or leucovorin and fluorouracil plus irinotecan (FOLFIRI). Serum iron may be a useful and convenient predictor of the response to chemotherapy; however, the mechanism underlying its increase has not been fully elucidated. Accordingly, the mechanism underlying the elevation of serum iron during chemotherapy was investigated in 20 patients with advanced CRC who were treated between September, 2012 and July, 2013. The levels of iron, ferritin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), hemoglobin (Hb), hepcidin-25, interleukin (IL)-6 and soluble transferrin receptor (sTfR) were measured before and 48 h after chemotherapy. The serum levels of iron and hepcidin-25 were found to be significantly increased after chemotherapy (P<0.0001), whereas those of IL-6 were significantly decreased (P=0.0057). There were no significant changes in any of the other parameters. The lack of significant changes in AST, ALT and Hb suggested that the elevation of serum iron was not due to the destruction of hepatocytes, whereas the stable sTfR level suggested no destruction of erythroblasts. Hepcidin-25 regulates iron metabolism and decreases serum iron levels; it is increased by an iron load and IL-6, but is decreased under anemic or hypoxic conditions. The suppression of erythropoiesis increases serum iron levels and chemotherapy suppresses erythropoiesis. As serum iron and hepcidin-25 were both significantly increased and IL-6 was significantly decreased, with no significant changes in sTfR, it appears that the elevation of serum iron during chemotherapy may be secondary to reduced iron consumption by erythropoiesis, leading to increased expression of hepcidin-25 and suppression of Il-6 via negative feedback.

Feasibility and advantages of transcanal endoscopic myringoplasty.

OBJECTIVE: When performing transcanal myringoplasty under a microscope, the total circumference of the perforation can be difficult to confirm in patients where the external ear canal is narrow and/or protruded. In such patients, a retroauricular incision approach is usually used. However, we have developed a transcanal endoscopic myringoplasty procedure, and the microscopic and endoscopic views are compared herein for the first time. The feasibility and advantages of transcanal endoscopic myringoplasty were examined. STUDY DESIGN: A prospective case series. SETTING: Tertiary referral center. PATIENTS: Transcanal endoscopic myringoplasty was performed on 25 ears in 21 patients with chronic otitis media between September 2011 and December 2012. INTERVENTION: Microscopic and endoscopic views were compared for each patient. The 2 fields of views were both recorded and evaluated to determine the advantages and disadvantages of microscopes and endoscopes. Myringoplasty was performed using an endoscopic technique while comparing views as necessary. RESULTS: Endoscopic views revealed the entire tympanic membrane in a single field with clear visualization of the perforation edges even when the ear canal was curved. This clear visualization facilitated reliable refreshing of the perforation edges and grafting. The anterior edge of the perforation was not visible under microscopy in 5 of 25 ears. Under an endoscopic wide view, the tympanic cavity was observable through the perforation, and the orifice of the tube, ossicular chain, and tympanic isthmus were visible especially with large perforations. Transcanal endoscopic myringoplasty was successfully performed with a simple underlay technique or with an intracanal incision in cases of marginal perforation. CONCLUSION: Comparison of microscopic and endoscopic views revealed superior visualization and operability of the endoscopic approach as opposed to transcanal simple underlay myringoplasty. Transcanal endoscopic myringoplasty does not require surgical exposure such as a retroauricular skin incision to get an anterior view. Our results demonstrated that transcanal endoscopic myringoplasty can be performed, regardless of the perforation size and the narrowness and/or protrusion of external ear canal.

Extension of indications for transcanal endoscopic ear surgery using an ultrasonic bone curette for cholesteatomas.

BACKGROUND: One-handed endoscopic procedures have, up until now, limited the indications for transcanal endoscopic ear surgery (TEES) in cholesteatoma surgery. However, the development of electrically powered instruments has opened the door to such one-handed endoscopic procedures in restricted surgical spaces. OBJECTIVE: We examined the feasibility of using one such powered instrument, the ultrasonic bone curette (UBC) in TEES for cholesteatoma surgery. The UBC offers several advantages, including nonrotational motion and the combination of both suction and irrigation in a single handpiece. STUDY DESIGN: A prospective case series. SETTING: Tertiary referral center. PATIENTS: TEES was performed on 43 cases of primary cholesteatoma between September 2011 and December 2012, including 14 cases extending to the antrum. INTERVENTION: Zero-, 30-, or 70-degree angled rigid endoscopes with an outer diameter of 2.7 mm (Karl Storz) were used together with a high-definition video system. A Sonopet UBC (Stryker) was used to cut bony tissue. The nonrotational motion of the UBC prevents injury to the tympanomeatal flap and other soft tissue, which may result with standard drills. Transcanal endoscopic retrograde mastoidectomy on demand was performed to access the pathologies in the attic and antrum. RESULTS: A minimum attico-antrotomy was performed using the UBC, removing only the bony tissue necessary to visualize the pathology. The cholesteatoma was completely removed from the antral mucosa under clear endoscopic visualization in 13 of 14 cases. After removal of the cholesteatoma, the canal wall was reconstructed using cartilage taken from the tragus. This procedure resulted in greater mastoid preservation. CONCLUSION: The transcanal endoscopic approach to the antrum using the UBC proved to be less invasive and more functional. The UBC contains both a suction and irrigation system in a single handpiece, and this UBC is an appropriate cutting tool that extends the indications for TEES.