Factors, Including Clinical Trial Eligibility, Associated with Induction of Third-Line Treatment for Advanced Gastric Cancer.

INTRODUCTION: Third-line chemotherapy has been suggested to improve survival in patients with gastric cancer. This study aimed to identify factors associated with the induction of third-line chemotherapy for advanced gastric cancer, focusing on patient eligibility for clinical trial. METHODS: We retrospectively analyzed 335 patients treated for unresectable or recurrent gastric cancer between April 2009 and May 2020. The patients were grouped into those that met the key eligibility criteria for clinical trial (136 patients, 40.6%) and those that did not (199 patients, 59.4%) before receiving first-line chemotherapy. RESULTS: The overall survival (OS) was 16.8 months (95% CI: 14.0-19.6) and 9.3 months (95% CI: 7.8-11.0) in the eligible and ineligible group, respectively. Multivariate analyses to identify the risk factors associated with the induction of third-line chemotherapy revealed ineligibility of clinical trial (OR 1.95; 95% CI: 1.15-3.31), number of metastatic sites (OR 1.99; 95% CI: 1.23-3.22), low albumin concentration (OR 2.24; 95% CI: 1.14-4.38), and a lack of complete or partial response to first-line treatment (OR 1.85; 95% CI: 1.05-3.26). Indeed, in responders to first-line treatment for ineligible patients, the median OS was 17.7 months (95% CI: 10.6-27.9), respectively. CONCLUSIONS: Treatment outcomes were different for those eligible for clinical trials and those who were not. However, this study suggested that patients who responded to first-line treatment have more favorable prognosis when treated with salvage chemotherapy, even if they were deemed ineligible for clinical trials.

Concurrent IgG4-related hypophysitis and clinically nonfunctioning gonadotroph pituitary neuroendocrine tumor.

BACKGROUND: Some patients develop immunoglobulin G4 (IgG4)-related hypophysitis associated with systemic diseases. More than 30 cases of IgG4-related hypophysitis have been reported. However, biopsy has rarely been performed in these patients, and none have had an associated pituitary neuroendocrine tumor (PitNET). We present a case of concurrent IgG4-related hypophysitis and PitNET. CASE PRESENTATION: A 56-year-old Japanese man arrived at the hospital with visual impairment, bitemporal hemianopia, and right abducens nerve palsy. Magnetic resonance imaging revealed pituitary body and stalk swelling as well as a small poorly enhanced right anterior lobe mass. Laboratory and loading test results suggested hypopituitarism. Because IgG4 level was elevated, a systemic examination was performed; multiple nodules were found in both lung fields. The diagnosis was based on an endoscopic transnasal biopsy of the pituitary gland. A histopathological examination revealed a marked infiltration of plasma cells into the pituitary gland, which was strongly positive for IgG4. The histological features of the resected tumor were consistent with those of gonadotroph PitNET, which was immunohistochemically positive for follicle-stimulating hormone-ß and steroidogenic factor-1, and no plasma cell infiltration was observed. Based on the histopathological examination results, steroid therapy was initiated, which reduced pituitary gland size and serum IgG4 levels. DISCUSSION AND CONCLUSIONS: This is the first reported case of IgG4-related hypophysitis with PitNET. Although no pathological findings indicating a relationship between the two conditions were found, we were able to preoperatively differentiate multiple lesions via detailed diagnostic imaging.

A Multicenter Prospective Validation Study on Selective Endoscopic Resection of Sessile Serrated Lesions Using Magnifying Colonoscopy in Clinical Practice.

INTRODUCTION: Sessile serrated lesions (SSLs) have malignant potential for colorectal cancer in the serrated pathway. Selective endoscopic resection of SSLs would reduce medical costs and procedure-related accidents, but the accurate endoscopic differentiation of SSLs from hyperplastic polyps (HPs) is challenging. To explore the differential diagnostic performance of magnifying colonoscopy in distinguishing SSLs from HPs, we conducted a multicenter prospective validation study in clinical practice. METHODS: Considering the rarity of diminutive SSLs, all lesions ≥6 mm that were detected during colonoscopy and diagnosed as type 1 based on the Japan narrow-band imaging expert team (JNET) classification were included in this study. Twenty expert endoscopists were asked to differentiate between SSLs and HPs with high or low confidence level after conventional and magnifying NBI observation. To examine the validity of selective endoscopic resection of SSLs using magnifying colonoscopy in clinical practice, we calculated the sensitivity of endoscopic diagnosis of SSLs with histopathological findings as comparable reference. RESULTS: A total of 217 JNET type 1 lesions from 162 patients were analyzed, and 114 lesions were diagnosed with high confidence. The sensitivity of magnifying colonoscopy in detecting SSLs was 79.8% (95% confidence interval [CI]: 74.7-84.4%) overall, and 82.4% (95% CI: 76.1-87.7%) in the high-confidence group. These results showed that the sensitivity of this study was not high enough, even limited in the high-confidence group. CONCLUSIONS: Accurate differential diagnosis of SSLs and HPs using magnifying colonoscopy was challenging even for experts. JNET type 1 lesions ≥6 mm are recommended to be resected because selective endoscopic resection has a disadvantage of leaving approximately 20% of SSLs on site.

Updates in narrow-band imaging for colorectal polyps: Narrow-band imaging generations, detection, diagnosis, and artificial intelligence.

Narrow-band imaging (NBI) is an optical digital enhancement method that allows the observation of vascular and surface structures of colorectal lesions. Its usefulness in the detection and diagnosis of colorectal polyps has been demonstrated in several clinical trials and the diagnostic algorithms have been simplified after the establishment of endoscopic classifications such as the Japan NBI Expert Team classification. However, there were issues including lack of brightness in the earlier models, poor visibility under insufficient bowel preparation, and the incompatibility of magnifying endoscopes in certain endoscopic platforms, which had impeded NBI from becoming standardized globally. Nonetheless, NBI continued its evolution and the newest endoscopic platform launched in 2020 offers significantly brighter and detailed images. Enhanced visualization is expected to improve the detection of polyps while universal compatibility across all scopes including magnifying endoscopy will promote the global standardization of magnifying diagnosis. Therefore, knowledge related to magnifying colonoscopy will become essential as magnification becomes standardly equipped in future models, although the advent of computer-aided diagnosis and detection may greatly assist endoscopists to ensure quality of practice. Given that most endoscopic departments will be using both old and new models, it is important to understand how each generation of endoscopic platforms differ from each other. We reviewed the advances in the endoscopic platforms, artificial intelligence, and evidence related to NBI essential for the next generation of endoscopic practice.

Performance of perioperative antibiotics against post-endoscopic submucosal dissection coagulation syndrome: a multicenter randomized controlled trial.

BACKGROUND AND AIMS: This study aimed to evaluate the efficacy of perioperative antibiotics against post-endoscopic submucosal dissection (ESD) coagulation syndrome (PECS) in patients undergoing colorectal ESD. METHODS: A prospective, multicenter, randomized controlled, parallel, superiority trial was conducted at 21 Japanese tertiary institutions. Patients with superficial colorectal lesions ≥20 mm and those undergoing ESD management for a single lesion were eligible. Patients with perforation during and after ESD were withdrawn. Before the ESD procedure, participants were randomly assigned (1:1) to either undergo conventional treatment (nonantibiotic group) or investigational treatment (antibiotic group). In the antibiotic group, 3 g of ampicillin-sulbactam was administered just before, 8 hours after, and the morning after ESD. The primary endpoint was the incidence of PECS. The onset of PECS was defined as localized abdominal pain (both spontaneous pain and tenderness) and fever (≥37.6°C) or inflammatory response (leukocytosis [≥10,000 cells/µL] or elevated C-reactive protein level [≥.5 mg/dL]). RESULTS: From February 5, 2019 to September 7, 2020, 432 patients were enrolled and assigned to the antibiotic group (n = 216) or nonantibiotic group (n = 216). After withdrawal of 52 patients, 192 in the antibiotic group and 188 in the nonantibiotic group were analyzed. PECS occurred in 9 of 192 patients (4.7%) in the antibiotic group and 14 of 188 patients (7.5%) in the nonantibiotic group, with an odds ratio of .61 (95% confidence interval, .23-1.56; P = .29). CONCLUSIONS: Perioperative use of antibiotics was not effective in reducing the incidence of PECS in patients undergoing colorectal ESD. (Clinical trial registration number: UMIN000035178.).

Linear Hydrocarbon Chain Growth from a Molecular Diruthenium Carbide Platform.

The formation of linear hydrocarbon chains by sequential coupling of C1 units on the metal surface is the central part of the Fischer-Tropsch (F-T) synthesis. Organometallic complexes have provided numerous models of relevant individual C-C coupling events but have failed to reproduce the complete chain lengthening sequence that transforms a linear Cn hydrocarbon chain into its Cn+1 homologue in an iterative fashion. In this work, we demonstrate stepwise growth of linear Cn hydrocarbon chains and their conversion to their Cn+1 homologues via consecutive addition of CH2 units on a molecular diruthenium carbide platform. The chain growth sequence is initiated by the formation of a µ-η1:η1-C═CH2 ligand from a C + CH2 coupling between the µ-carbido complex [(Cp*Ru)2(η-NPh)(µ-C)] (1; Cp* = η5-C5Me5) and Ph2SCH2. Then, the chain propagates via a general C═CHR + CH2 coupling and subsequent hydrogen-assisted isomerization of the resulting allene ligand µ-η1:η3-H2C═C═CHR to a higher vinylidene homologue µ-η1:η1-C═CH(CH2)R. By repeating this reaction sequence, up to C6 chains have been synthesized in a stepwise fashion. The key step of this chain homologation sequence is the selective hydrogenation of the µ-η1:η3-allene unit to the corresponding µ-alkylidene ligand. Isotope labeling and computational studies indicate that this transformation proceeds via the hydrogenation of the allene ligand to a terminal alkene form and its isomerization to the µ-alkylidene ligand facilitated by the coordinatively unsaturated diruthenium platform.

Factors associated with inaccurate size estimation of colorectal polyps: A multicenter cross-sectional study.

BACKGROUND AND AIM: Accurate polyp size estimation is essential in deciding the therapeutic strategy of colorectal polyps and endoscopic surveillance intervals. However, many endoscopists frequently make incorrect size estimations without being aware of their errors. This cross-sectional study aimed to clarify the characteristics of endoscopists associated with inaccurate estimation. METHODS: We previously conducted a web trial involving 261 endoscopists in 51 institutions in Japan to assess their ability to estimate polyp size. Participants answered questions about polyp size using visual estimates in a test involving images of 30 polyps. Here, we investigated the relationships between inaccurate size estimation and the backgrounds of participants. The rates of overestimation and underestimation of polyp size were also compared to clarify any trends in the answers of participants with low accuracy (< 50%). RESULTS: Multivariable logistic regression analysis revealed that the number of colonoscopic procedures in the past year was the only factor associated with a low accuracy of polyp size estimation (odds ratio 0.750, 95% confidence interval 0.609-0.925; P = 0.007). Endoscopists with low accuracy had a greater tendency to overestimate polyp size (42.3% overestimation and 21.2% underestimation, P < 0.001) compared with other endoscopists (16.6% overestimation and 17.9% underestimation, P = 0.951). CONCLUSIONS: Endoscopists with limited experience of colonoscopy in the past year were more likely to make frequent errors in size estimation. Furthermore, endoscopists making inaccurate size estimations had a propensity to overestimate polyp size.

Clinical importance of cold polypectomy during the insertion phase in the left side of the colon and rectum: a multicenter randomized controlled trial (PRESECT study).

BACKGROUND AND AIMS: Colorectal polyps are often detected during the insertion phase of colonoscopy but are commonly removed during the withdrawal phase. We aimed to investigate the clinical advantages of instant removal of colorectal polyps during the insertion phase to determine the appropriate strategy for polyps detected on insertion. METHODS: This prospective, multicenter, randomized trial targeted patients with at least 1 left-sided polyp <10 mm in size detected unintentionally on endoscope insertion from April 2018 to March 2019. Patients were allocated to the following 2 groups: study group, consisting of patients who had polyp removal instantly on insertion, and control group, comprising patients who had the endoscope inserted to the cecum first and polyps removed subsequently on withdrawal. Carbon dioxide gas insufflation and cold polypectomy were applied to minimize the influences of polypectomy on endoscope insertion. Twenty advanced endoscopists from 7 community-based institutions participated in this trial. RESULTS: Of 1451 patients enrolled, 220 patients were eligible for full assessment. Mean total procedure time was significantly shorter in the study group (18.9 vs 22.3 minutes, P < .001). Mean pure cecal intubation time and number of polyps per patient were similar between the 2 groups. In the control group, among 107 polyps found during insertion, 48 (45.8%) required reinspection and 7 (6.5%) were completely missed, with an average reinspection time of approximately 3 minutes. CONCLUSIONS: Polypectomy during the insertion phase in the colon and rectum significantly shortens the total procedure time and eliminates all missed polyps without experiencing any disadvantages.

Short educational video to improve the accuracy of colorectal polyp size estimation: Multicenter prospective study.

BACKGROUND AND AIM: Accurate polyp size estimation is necessary for appropriate management of colorectal polyps. Polyp size is often determined by subjective visual estimation in clinical situations; however, it is inaccurate, especially for beginner endoscopists. We aimed to clarify the usefulness of our short training video, available on the Internet, for accurate polyp size estimation. METHODS: We conducted a multicenter prospective controlled study in Japan. After completing a pretest composed of near and far images of 30 polyps, participants received the educational video lecture (<10 min long). The educational content included the knowledge of strategies based on polyp size and criteria for size estimation including the endoscopic equipment size and videos of polyps in vivo. After one month, the participants undertook a posttest. The primary outcome was a change in the accuracy of polyp size visual estimation between the pretest and posttest in beginners. RESULTS: Participants including 111 beginners, 52 intermediates, and 97 experts from 51 institutions completed both tests. Accuracy of polyp size estimation in the beginners showed a significant increase after the video lecture [54.1% (51.3-57.0%) to 59.0% (56.5-61.5%), P = 0.003]. Multivariable logistic regression analysis showed that the category of beginners and a low score on pretest (P = 0.020 and <0.001, respectively) were the factors that contributed to an increase of ≥10% in the accuracy. CONCLUSION: Our educational video led to an improvement in polyp size estimation in beginners. Furthermore, this video may be useful for non-beginners with insufficient polyp size estimation accuracy.

Occipital lobe epilepsy was presented in a patient with intracerebral schwannoma: a case report and literature review.

Schwannoma arising within brain parenchyma is a rare scenario. So far, only 70 cases were reported. We reported a case of intracerebral schwannoma presented with occipital lobe epilepsy, which has never been reported before. A 19-year-old man suffered from intermittent blurred vision and headache. Neuroradiological findings showed a left occipital lesion with cystic and solid components. Histological and electron micrograph features confirmed the diagnosis of schwannoma after the tumor was totally removed. The theories and literature related to this case were reviewed and the possible developmental origin was discussed. We found that this kind of schwannoma is more often in adolescent and young adults.

Standards of diagnostic colonoscopy for early-stage neoplasia: Recommendations by an Asian private group.

BACKGROUND AND AIM: In recent years, the incidence of colorectal cancer has been increasing, and it is now becoming the major cause of cancer death in Asian countries. The aim of the present study was to develop Asian expert-based consensus to standardize the preparation, detection and characterization for the diagnosis of early-stage colorectal neoplasia. METHODS: A professional group was formed by 36 experts of the Asian Novel Bio-Imaging and Intervention Group (ANBI2 G) members. Representatives from 12 Asia-Pacific countries participated in the meeting. The group organized three consensus meetings focusing on diagnostic endoscopy for gastrointestinal neoplasia. The Delphi method was used to develop the consensus statements. RESULTS: Through the three consensus meetings with debating, reviewing the literature and regional data, a consensus was reached at third meeting in 2016. The consensus was reached on a total of 10 statements. Summary of statements is as follows: (i) Adequate bowel preparation for high-quality colonoscopy; (ii) Antispasmodic agents for lesion detection; (iii) Image-enhanced endoscopy (IEE) for polyp detection; (iv) Adenoma detection rate for quality indicators; (v) Good documentation of colonoscopy findings; (vi) Complication rates; (vii) Cecal intubation rate; (viii) Cap-assisted colonoscopy (CAC) for polyp detection; (ix) Macroscopic classification using indigocarmine spray for characterization of colorectal lesions; and (x) IEE and/or magnifying endoscopy for prediction of histology. CONCLUSION: This consensus provides guidance for carrying out endoscopic diagnosis and characterization for early-stage colorectal neoplasia based on the evidence. This will enhance the quality of endoscopic diagnosis and improve detection of early-stage colorectal neoplasia.

Additional chromoendoscopy for colorectal lesions initially diagnosed with low confidence by magnifying narrow-band imaging: Can it improve diagnostic accuracy?

BACKGROUND AND AIM: Magnifying chromoendoscopy has been one of the most reliable diagnostic methods for distinguishing neoplastic from non-neoplastic lesions. The aim of this prospective study was to clarify the clinical usefulness of magnifying chromoendoscopy for colorectal polyps initially diagnosed with low confidence (LC) by magnifying narrow-band imaging (NBI). METHODS: Consecutive adult patients who underwent total colonoscopic examination with magnifying NBI between July and December 2016 at Sano Hospital were prospectively recruited. Endoscopists were asked to carry out additional magnifying chromoendoscopy for cases that had been initially diagnosed as Japan NBI Expert Team (JNET) Type 1 or 2A with LC by magnifying NBI. We investigated the diagnostic performance of magnifying NBI for polyps diagnosed as JNET Type 1 or 2A with LC (first phase) and that of subsequent magnifying chromoendoscopy (second phase) in differentiating neoplasia from non-neoplasia. RESULTS: In 50 patients, we analyzed 53 polyps classified as JNET Type 1 or 2A with LC prediction. Accuracy and negative predictive value of magnifying NBI (first phase) were 58.5% (95% CI, 44.1-71.9%) and 66.0% (95% CI, 36.6-77.9%), and those of magnifying chromoendoscopy (second phase) were 66.0% (95% CI, 51.7-78.5%) and 61.1% (95% CI, 43.5-76.9%), respectively. CONCLUSION: Regardless of the findings of additional chromoendoscopy, all polyps should be resected and submitted for histopathological examination when the confidence level in differentiating adenomatous from hyperplastic polyps by magnifying NBI is low.

Growth Hormone Therapy and Brain Tumors.

As one of the projects of the Adverse Events Study Group of the Foundation for Growth Science in Japan, the literatures on the recurrence and / or regrowth or new formation of brain tumors in patients treated with growth hormone (GH) were reviewed. Since the tumor volume of the sellar lesion can be accurately evaluated only by magnetic resonance imaging (MRI), the related literatures published after 1990 were retrieved by searching under keywords, such as GH, replacement therapy, brain tumor, recurrence, tumor formation, etc. It is undeniable that GH therapy may result in tumor enlargement only in a very small percentage of cases. However, within a scientifically reliable range of confirmation with large-scale researches and case-control studies, it can be considered that there is no relation between GH therapy and the recurrence or new formation of brain tumors.

[A Case of a Solitary Plasmacytoma Extending into the Extradural Space].

Plasmacytomas are characterized by a monoclonal proliferation of plasma cells, and constitute the bulk of multiple myeloma. A solitary plasmacytoma is a rare entity, and is even more unlikely to occur intracranially. Here we present a 62-year-old man with an intracranial tumor. Magnetic resonance imaging revealed a large mass on the surface of the right fronto-parieto-temporal region, with extradurally directed growth. The tumor was enhanced homogenously by gadolinium, with dural tail-like findings, which resembled a meningioma. Head computed tomography scan showed osteolytic changes of the calvarium. Tumor removal following intravascular embolization was performed. The tumor seemed to have developed from the dura mater because it was firmly adhered to the dura but not to the calvarium. Histopathological analysis revealed monoclonal proliferation of plasma cells, which were positive for CD56, CD138, and lambda chain, on immunostaining. Since a systemic examination showed no evidence of other lesions, we diagnosed the tumor as a solitary dural plasmacytoma. There was no recurrence after postoperative radiotherapy. Rare entities, such as a solitary plasmacytoma, should be considered when an intracranial lesion with atypical radiological features is observed. If the lesion is anatomically resectable, histopathological evaluation is essential.

[A Case of Bilateral Traumatic Carotid-Cavernous Fistula].

Bilateral traumatic carotid-cavernous fistula(CCF)is rare. It is most commonly caused by a direct head or face injury involving the cavernous sinus and develops immediately after trauma. We report a case of bilateral traumatic CCF that occurred as an intracerebral hematoma(ICH)mimicking apoplexy 5 months later. We treated the patient with point occlusion of venous reflux causing an ICH using coil embolization to remove the hematoma. Three days after we performed trans-venous occlusion of the intercavernous connection and right cavernous sinus using coil embolization through the right inferior petrosal vein, it was identified that the left CCF was occluded after first embolization into the left sylvian vein. The mechanism of delayed development of traumatic CCF and spontaneous disappearance of CCF after occlusion of venous reflux are discussed.

Modulation of circulating endothelial progenitor cells by erythropoiesis-stimulating agents in patients with chronic kidney disease stage G5 and 5D
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AIMS: Circulating endothelial progenitor cells (EPCs) play a pivotal role in vasculogenesis and promote angiogenesis by secreting growth factors. Recent studies have suggested that erythropoietin (EPO) may accelerate not only angiogenesis but also vasculogenesis, beyond erythropoiesis. The aim of this study was to investigate whether two erythropoiesis-stimulating agents (ESAs) modulate vascular-related factors and EPC mobilization in patients with chronic kidney disease stage G5 and dialysis (CKD G5 and 5D). MATERIALS AND METHODS: We conducted a 12-week prospective study in 63 patients; 21 patients received recombinant human erythropoietin (rhEPO) (EPO group, 4,565.5 ± 1,994.4 IU/week), 21 patients received darbepoetin (DA) (DA group, 40.1 ± 13.8 µg/week), and 21 patients received no ESAs (no-ESA group). Vascular mediators, including EPCs, vascular endothelial growth factor, matrix metalloproteinase-2 (MMP-2), high-sensitivity C-reactive protein, and asymmetric dimethyl arginine, were measured at 0 and 12 weeks. EPCs were measured by flow cytometry as CD45lowCD34+CD133+ cells. We also performed a subanalysis of dialysis (5D) patients (n = 32) in the three groups. RESULTS: In the EPO group, EPC count increased significantly from 0 to 12 weeks in a dose-dependent manner (r = 0.62, p = 0.005), and the increase was more conspicuous in the subgroup of dialysis 5D patients. In the DA group, the EPC number did not change at 12 weeks. Neither rhEPO nor DA affected the serum levels of the aforementioned biomarkers other than EPC. ;Conclusion: We speculate that the pleiotropic effects of rhEPO and DA beyond their hematopoietic effects may differ between CKD G5 and 5D patients.
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The feasibility of detecting cerebral blood flow direction using the indocyanine green video angiography.

The intraoperative confirmation of blood flow direction is necessary in cerebral vascular surgery. Using indocyanine green video angiography (ICG-VAG) with the FLOW 800 system, we examined the transit time of the blood vessel of interest and semiquantitatively evaluated the delay time (T1/2max) from indocyanine green (ICG) injection into the donor artery in reconstructive surgery and the middle cerebral artery (MCA) in aneurysmal surgery. The direction of cerebral blood flow (CBF), which can often be confirmed by ICG-VAG, may be more difficult to determine with faster blood flow. Here, we report our findings regarding the feasibility of detecting CBF direction using the FLOW 800 system. Twenty patients undergoing superficial temporal artery (STA) to MCA anastomosis for carotid occlusive disease and 13 patients with a small MCA aneurysm clipping were evaluated using the T1/2max, semiquantitative method with the FLOW 800 system. In STA-MCA anastomosis cases, the regions of interest (ROIs) included: the proximal donor STA and a region more than 10 mm on the distal side of the donor STA near the anastomosis site. In MCA aneurysms, the ROIs included the proximal M1 and distal M2 sides of the MCA aneurysm. T1/2max was significantly shorter for the proximal sites compared to the distal sites for all subjects (ps < 0.01). T1/2max was shorter for all subjects in the proximal sites. The direction of CBF can be determined using the FLOW 800 system.

Long-term patency of superficial temporal artery to middle cerebral artery bypass for cerebral atherosclerotic disease: factors determining the bypass patent.

Long-term patency of superficial temporal artery to middle cerebral artery (STA-MCA) bypass surgery for atherosclerotic disease and associated risk factors for loss of patency have rarely been discussed. We retrospectively analyzed long-term patency following STA-MCA bypass and evaluated various demographic and clinical factors to identify the ones predictive of postsurgical loss of patency using records of 84 revascularization procedures (58 patients, 45 males; mean age at surgery 63.6 years, range 31-78 years). Bypass patency was diagnosed based on magnetic resonance angiography or three-dimensional computed tomography. The mean follow-up period was 24.7 months (range 6-63 months). Decreased bypass patency was observed in 4 of 58 patients (6.9 %) who collectively underwent 6 bypasses (7.1 %) of 84. All cases of decreased bypass patency were first detected within 6 months of surgery. Bypass patency was not correlated with age, sex, number of anastomoses, postoperative cerebral infarction, or control of postoperative diabetes mellitus. We found a significant association of bypass patency with hyperperfusion (p = 0.01) and postoperative smoking (p = 0.0036). Furthermore, we found a significant association of hyperperfusion with STA diameter (p < 0.0001), location of anastomosis (p = 0.075), and preoperative cerebral blood flow (p = 0.0399). In our retrospective study, hyperperfusion and smoking after surgery may be risk factors for decreased bypass patency in cerebral atherosclerotic disease patients. Careful monitoring of patency to prevent hyperperfusion and cessation of smoking are recommended, particularly within 6 months of the surgery.

Olfactory preservation during anterior interhemispheric approach for anterior skull base lesions: technical note.

Anosmia is not a rare complication of surgeries that employ the anterior interhemispheric approach. Here, we present a fibrin-gelatin fixation method that provides reinforcement and moisture to help preserve the olfactory nerve when using the anterior interhemispheric approach and describe the results and outcomes of this technique. We analyze the outcomes with this technique in 45 patients who undergo surgery for aneurysms, brain tumors, or other pathologies via the anterior interhemispheric approach. Anosmia occurred in 4 patients (8.8%); it was transient in 2 (4.4%) and permanent in the remaining 2 (4.4%). Brain tumors clearly attached to the olfactory nerve were resected in the patients with permanent anosmia. We found a significant difference in the presence of anosmia between patients with or without lesions that were attaching the olfactory nerve (p = 0.011). Our results suggested that fibrin-gelatin fixation method can reduce the reported risk of anosmia. However, the possibility of olfactory nerve damage is relatively high when operating on brain tumors attaching olfactory nerve.

Effects of financial support on treatment of adolescents with growth hormone deficiency: a retrospective study in Japan.

BACKGROUND: Treatment costs for children with growth hormone (GH) deficiency are subsidized by the government in Japan if the children meet clinical criteria, including height limits (boys: 156.4 cm; girls: 145.4 cm). However, several funding programs, such as a subsidy provided by local governments, can be used by those who exceed the height limits. In this study, we explored the impacts of financial support on GH treatment using this natural allocation. METHODS: A retrospective analysis of 696 adolescent patients (451 boys and 245 girls) who reached the height limits was conducted. Associations between financial support and continuing treatment were assessed using multiple logistic regression analyses adjusting for age, sex, height, growth velocity, bone age, and adverse effects. RESULTS: Of the 696 children in the analysis, 108 (15.5 %) were still eligible for financial support. The proportion of children who continued GH treatment was higher among those who were eligible for support than among those who were not (75.9 % vs. 52.0 %, P < 0.001). The odds ratios of financial support to continuing treatment were 4.04 (95 % confidence interval [CI]: 1.86-8.78) in boys and 1.72 (95 % CI: 0.80-3.70) in girls, after adjusting for demographic characteristics and clinical factors. CONCLUSIONS: Financial support affected decisions on treatment continuation for children with GH deficiency. Geographic variations in eligibility for financial support pose an ethical problem that needs policy attention. An appropriate balance between public spending on continuation of therapy and improved quality of life derived from it should be explored.