Real-world safety and effectiveness of intravenous fomepizole in patients with ethylene glycol and methanol poisoning in Japan: results of a 7-year post-marketing surveillance study.

BACKGROUND: Fomepizole is a competitive alcohol dehydrogenase inhibitor used for the treatment of ethylene glycol and methanol poisoning. We evaluated the safety and effectiveness of fomepizole in patients with ethylene glycol or methanol poisoning in Japan. RESEARCH DESIGN AND METHODS: This retrospective post-marketing surveillance study conducted in Japan registered patients who received fomepizole intravenous infusion per the package insert (January 2015-June 2022). Endpoints included adverse drug reactions/infections (ADRs), arterial blood pH, and treatment outcomes. RESULTS: Of 147 patients registered (91 institutions), 131 and 126 were included in the safety and effectiveness analysis sets, respectively. Mean age was 43.6 years, and 66.4% were male. Mean time from poison ingestion to treatment was 15.1 hours; 66.4% received concomitant hemodialysis. No serious ADRs were reported. ADRs were reported in seven patients; the most-reported ADR was vomiting (2.3%). Seven patients died, 105 survived without sequelae, and 19 survived with sequelae. Most common sequelae were renal failure or renal dysfunction. Mean arterial blood pH increased to 7.4 by 4 hours of treatment, remaining stable for 24 hours post-treatment. CONCLUSIONS: Fomepizole is well tolerated and helps improve clinical outcomes in patients with ethylene glycol or methanol poisoning in Japan. TRIAL REGISTRATION: Japanese Pharmaceutical Information Center (JapicCTI-152817).

Dose-averaged LET optimized carbon-ion radiotherapy for head and neck cancers.

This feasibility study confirmed the initial safety and efficacy of a novel carbon-ion radiotherapy (CIRT) using linear energy transfer (LET) painting for head and neck cancer. This study is the first step toward establishing CIRT with LET painting in clinical practice and making it a standard practice in the future.

A novel approach to predict acute radiation dermatitis in patients with head and neck cancer using a model based on Bayesian probability.

PURPOSE: In this study, we aimed to establish a method for predicting the probability of each acute radiation dermatitis (ARD) grade during the head and neck Volumetric Modulated Arc Therapy (VMAT) radiotherapy planning phase based on Bayesian probability. METHODS: The skin dose volume >50 Gy (V50), calculated using the treatment planning system, was used as a factor related to skin toxicity. The empirical distribution of each ARD grade relative to V50 was obtained from the ARD grades of 119 patients (55, 50, and 14 patients with G1, G2, and G3, respectively) determined by head and neck cancer specialists. Using Bayes' theorem, the Bayesian probabilities of G1, G2, and G3 for each value of V50 were calculated with an empirical distribution. Conversely, V50 was obtained based on the Bayesian probabilities of G1, G2, and G3. RESULTS: The empirical distribution for each graded patient group demonstrated a normal distribution. The method predicted ARD grades with 92.4 % accuracy and provided a V50 value for each grade. For example, using the graph, we could predict that V50 should be ≤24.5 cm3 to achieve G1 with 70 % probability. CONCLUSIONS: The Bayesian probability-based ARD prediction method could predict the ARD grade at the treatment planning stage using limited patient diagnostic data that demonstrated a normal distribution. If the probability of an ARD grade is high, skin care can be initiated in advance. Furthermore, the V50 value during treatment planning can provide radiation oncologists with data for strategies to reduce ARD.

Laparoscopic left hepatectomy in a goat as a training model for laparoscopic anatomic liver resection: results of training courses with a total of 70 goats.

BACKGROUND: To create a suitable animal model for the training of laparoscopic anatomic liver resection, we performed left hepatectomy using a goat and found its suitability. We have since started using goats for wet-lab training and have gradually standardized the relevant procedures. Herein, we report our standardized training procedures using a goat and discuss its feasibility as a novel training model. METHODS: The standardized wet-lab training courses of laparoscopic liver resection conducted on 62 tables with a total of 70 goats were reviewed. The training course began by encircling the hepatoduodenal ligament for the Pringle maneuver, which was repeated during the parenchymal dissection. Following partial liver resection of the left lateral section, left hepatectomy was performed by a standardized procedure for humans in which the liver was split, exposing the entire length of the middle hepatic vein trunk from the dorsal side after extrahepatic transection of the left Glissonean pedicle. If a goat deceased before initiating left hepatectomy, the training was restarted with a new goat. The surgical procedures were performed by surgeons of varying skill levels. RESULTS: A total of 184 surgeons including 10 surgical residents participated in the training. Partial liver resection was initiated in 62 tables, with 8 (13%) dying during or after the procedure of partial liver resection. Subsequently, left hepatectomy was initiated in 61 and completed in 59 tables (98%), regardless of whether the goat survived or deceased, and was not completed in 2 tables (3%) due to time limitation. In 14 tables (23%), the goats deceased during the procedure, however, the procedure was completed. The causes of death were multifactorial, including massive bleeding, reperfusion injury after the Pringle maneuver, and carbon dioxide gas embolism. CONCLUSIONS: Left hepatectomy in a goat is useful as a training model for laparoscopic anatomic liver resection.

Acute Pancreatitis in Japan: Comparison of Before and After Revision of the Clinical Guidelines.

OBJECTIVES: Cases of acute pancreatitis (AP) are increasing worldwide, and mortality remains high in severe cases. In 2015, the Japanese guidelines for the management of AP were revised. We aimed to clarify the clinical practice of AP in Japan and its trend during the revision of the guidelines using a Japanese nationwide administrative database. METHODS: We retrospectively analyzed 102,119 patients with AP who were hospitalized between April 2014 and March 2018. The study period was divided into the first period (the time before the revision: fiscal years 2014 and 2015) and second period (after the revision: 2016 and 2017). RESULTS: Severe cases of AP accounted for 27.7% of total cases. The in-hospital mortality in severe cases was 5.7%. The mortality within 14 days of admission improved from 3.2% in the first period to 2.6% in the second period (P = 0.022). Referred patients had more severe diseases and a higher mortality. The mortality in patients who underwent endoscopic ultrasound-guided fistuloplasty for local complications (11.6%) was lower than that in patients who underwent percutaneous drainage (23.4%) or AP surgery (22.6%) (P < 0.001). CONCLUSIONS: We clarified the clinical practice of AP including the improved mortality after the revision of the guidelines.

Clinical features and prognostic impact of asymptomatic pancreatic cancer.

Pancreatic ductal adenocarcinoma (PDAC) is highly lethal, and early diagnosis is challenging. Because patients who present with symptoms generally have advanced-stage diseases, analysis of asymptomatic PDAC provides invaluable information for developing strategies for early diagnosis. Here, we reviewed 577 patients with PDAC (372 diagnosed with symptoms [symptomatic group] and 205 without symptoms [asymptomatic group]) diagnosed at our institute. Among the 205 asymptomatic PDAC patients, 109 were detected during follow-up/work-up for other diseases, 61 because of new-onset or exacerbation of diabetes mellitus, and 35 in a medical check-up. Asymptomatic PDAC is characterized by smaller tumor size, earlier disease stage, and higher resectability than those of symptomatic PDAC. In 22.7% of asymptomatic cases, indirect findings, e.g., dilatation of the main pancreatic duct, triggered PDAC detection. Although pancreatic tumors were less frequently detected, overall abnormality detection rates on imaging studies were nearly 100% in asymptomatic PDAC. Asymptomatic PDAC had a better prognosis (median survival time, 881 days) than symptomatic PDAC (342 days, P < 0.001). In conclusion, diagnosis of PDAC in the asymptomatic stage is associated with early diagnosis and a better prognosis. Incidental detection of abnormal findings during the follow-up/work-up for other diseases provides important opportunities for early diagnosis of asymptomatic PDAC.

Selective Photo-Crosslinking Detection of Methylated Cytosine in DNA Duplex Aided by a Cationic Comb-Type Copolymer.

In the process of cell development and differentiation, C-5-methylation of cytosine (5-methylcytosine: 5-mC) in genome DNA is an important transcriptional regulator that switches between differentiated and undifferentiated states. Further, abnormal DNA methylations are often present in tumor suppressor genes and are associated with many diseases. Therefore, 5-mC detection technology is an important tool in the most exciting fields of molecular biology and diagnosing diseases such as cancers. In this study, we found a novel photo-crosslinking property of psoralen-conjugated oligonucleotide (Ps-Oligo) to the double-stranded DNA (ds-DNA) containing 5-mC in the presence of a cationic comb-type copolymer, poly(allylamine)-graft-dextran (PAA-g-Dex). Photo-crosslinking efficiency of Ps-Oligo to 5-mC in ds-DNA was markedly enhanced in the presence of PAA-g-Dex, permitting 5-mC-targeted crosslinking. We believe that the combination of PAA-g-Dex and Ps-Oligo will be an effective tool for detecting 5-mC in genomic DNA.

A New Preoperative Scoring System for Predicting Aggressiveness of Non-Functioning Pancreatic Neuroendocrine Neoplasms.

The management of non-functioning pancreatic neuroendocrine neoplasms (NF-PanNENs) is still controversial. This study aimed to develop a new scoring system for treatment decisions at initial diagnosis based on the identification of the predictive factors for aggressive NF-PanNENs. Seventy-seven patients who had been pathologically diagnosed with NF-PanNENs were enrolled. We retrospectively reviewed 13 variables that could be assessed preoperatively. Univariate and multivariate stepwise logistic regression analyses were performed to identify factors for the aggressiveness of NF-PanNENs, and a scoring system was developed by assigning weighted points proportional to their ß regression coefficient. Tumor size > 20 mm on contrast-enhanced computed tomography, tumor non-vascularity, and Ki-67 labeling index ≥5% on endoscopic ultrasound-guided fine-needle aspiration specimens were identified as independent factors for predicting the aggressiveness of NF-PanNENs. The new scoring system, developed using the identified factors, had an excellent discrimination ability, with area under the curve of 0.92 (95% CI, 0.85-0.99), and good calibration (p = 0.72, Hosmer-Lemeshow test). Ten-year overall survival rates in low-risk (0 point), intermediate-risk (1 to 2 points), and high-risk (3 to 4 points) groups were 100%, 90.9%, and 24.3%, respectively. This new scoring system would be useful for treatment decisions and prognostic prediction at initial diagnosis.

Hematochezia Due to Panitumumab-induced Colitis with Vitamin K Deficiency.

Panitumumab, a fully human anti-epidermal growth factor receptor (EGFR) monoclonal antibody, has been shown to be useful in treating either advanced or recurrent KRAS/NRAS/BRAF wild-type colorectal cancer. We herein report the case of a 60-year-old man with short bowel syndrome who developed hematochezia due to panitumumab-induced colitis with vitamin K deficiency during third-line chemotherapy. The cause of vitamin K deficiency was the lack of intravenous vitamin K supplementation following a change from central venous nutrition to peripheral venous nutrition. We advise clinicians to carefully check for colitis and manage the infusions of chemotherapy patients with short bowel syndrome.

Ras signaling and RREB1 are required for the dissociation of medial edge epithelial cells in murine palatogenesis.

Cleft palate is one of the major congenital craniofacial birth defects. The etiology underlying the pathogenesis of cleft palate has yet to be fully elucidated. Dissociation of the medial edge epithelium (MEE) at the contacting region of palatal shelves and subsequent migration or apoptosis of MEE cells is required for proper MEE removal. Ras-responsive element-binding protein 1 (RREB1), a RAS transcriptional effector, has recently been shown to play a crucial role in developmental epithelial-mesenchymal transition (EMT), in which loss of epithelial characteristics is an initial step, during mid-gastrulation of embryonic development. Interestingly, the involvement of RREB1 in cleft palate has been indicated in humans. Here, we demonstrated that pan-Ras inhibitor prevents the dissociation of MEE during murine palatal fusion. Rreb1 is expressed in the palatal epithelium during palatal fusion, and knockdown of Rreb1 in palatal organ culture resulted in palatal fusion defects by inhibiting the dissociation of MEE cells. Our present findings provide evidence that RREB1-mediated Ras signaling is required during palatal fusion. Aberrant RREB1-mediated Ras signaling might be involved in the pathogenesis of cleft palate.

Focal Parenchymal Atrophy of the Pancreas Is Frequently Observed on Pre-Diagnostic Computed Tomography in Patients with Pancreatic Cancer: A Case-Control Study.

Pancreatic ductal adenocarcinoma (PDAC) accounts for the majority of all pancreatic cancers and is highly lethal. Focal parenchymal atrophy (FPA) of the pancreas has been reported as a characteristic imaging finding of early PDAC. Here, we reviewed 76 patients with PDAC who underwent computed tomography (CT) between 6 months and 3 years before PDAC diagnosis, as well as 76 sex- and age-matched controls without PDAC on CT examinations separated by at least 5 years. FPA was observed corresponding to the location of the subsequent tumor on pre-diagnostic CT in 14/44 (31.8%) patients between 6 months and 1 year, 14/51 (27.5%) patients between 1 and 2 years, and 9/41 (22.0%) patients between 2 and 3 years before PDAC diagnosis. Overall, FPA was more frequently observed in patients with PDAC (26/76; 34.2%) on pre-diagnostic CT than that in controls (3/76; 3.9%) (p < 0.001). FPA was observed before the appearance of cut-off/dilatation of the main pancreatic duct, suggesting that FPA might be the earliest sign of PDAC. FPA was less frequently found in tumors in the pancreatic head (3/27; 11.1%) than in those in the body (14/30; 46.7%) or tail (9/19; 47.4%). FPA may predict the subsequent PDAC diagnosis, serving as an important imaging sign for the early diagnosis of pancreatic cancer.

Acinar Cell Carcinoma with Morphological Change in One Month.

A 64-year-old man was admitted to our hospital to undergo examination of a pancreatic tumor accompanied by sudden epigastric pain. The tumor had a well-defined oval shape that was mostly less enhanced, with the exception of part of the tumor on the pancreatic head side, on contrast enhanced (CE)-CT. However, CE-CT performed one-month later revealed that the viable part of the tumor grew toward the pancreatic tail with the reduction of necrotic tissue. We performed distal pancreatectomy and the tumor was diagnosed as acinar cell carcinoma (ACC). One important characteristic of ACC is that it may develop morphological changes within a short period of time.

IgG4-related Diaphragmatic Inflammatory Pseudotumor.

A 71-year-old man underwent surgery for a pancreatic neuroendocrine tumor. Follow-up imaging showed swelling of the remnant pancreas, and he was histologically diagnosed with autoimmune pancreatitis based on endoscopic ultrasonography-guided fine-needle aspiration specimens. After two years, a tumor appeared on the liver surface. Although we planned to perform laparoscopic partial hepatectomy, the intraoperative findings showed that the tumor was located in the diaphragm. Partial resection of the diaphragm was performed, and the final diagnosis was an immunoglobulin G4-related inflammatory pseudotumor in the diaphragm. To our knowledge, this is the first reported case of an immunoglobulin G4-related diaphragmatic inflammatory pseudotumor.

Consistent modelling of material weight loss and gas release due to pyrolysis and conducting benchmark tests of the model-A case for glovebox panel materials such as polymethyl methacrylate.

It is necessary to consider how a glove box's confinement function will be lost when evaluating the amount of radioactive material leaking from a nuclear facility during a fire. In this study, we build a model that consistently explains the weight loss of glove box materials because of heat input from a flame and accompanying generation of the pyrolysis gas. The weight loss suggests thinning of the glove box housing, and the generation of pyrolysis gas suggests the possibility of fire spreading. The target was polymethyl methacrylate (PMMA), used as the glove box panel. Thermal gravimetric tests on PMMA determined the parameters to be substituted in the Arrhenius equation for predicting the weight loss in pyrolysis. The pyrolysis process of PMMA was divided into 3 stages with activation energies of 62 kJ/mol, 250 kJ/mol, and 265 kJ/mol. Furthermore, quantifying the gas composition revealed that the composition of the pyrolysis gas released from PMMA can be approximated as 100% methyl methacrylate. This result suggests that the released amount of methyl methacrylate can be estimated by the Arrhenius equation. To investigate the validity of such estimation, a sealed vessel test was performed. In this test, we observed increase of the number of gas molecules during the pyrolysis as internal pressure change of the vessel. The number of gas molecules was similar to that estimated from the Arrhenius equation, and indicated the validity of our method. Moreover, we also performed the same tests on bisphenol-A-polycarbonate (PC) for comparison. In case of PC, the number of gas molecules obtained in the vessel test was higher than the estimated value.

New-Onset or Exacerbation of Diabetes Mellitus Is a Clue to the Early Diagnosis of Pancreatic Cancer.

Pancreatic ductal adenocarcinoma (PDAC), which accounts for majority of pancreatic cancers, is one of the most lethal human malignancies. Most patients are diagnosed at an advanced stage after symptom development. Early diagnosis of PDAC in asymptomatic subjects is important to improve prognosis. Diabetes mellitus (DM) is a risk factor for PDAC, and DM, especially new-onset DM, has attracted attentions as a diagnostic clue to PDAC. However, the impact of DM as a diagnostic opportunity on the prognosis of PDAC is unclear. We here retrospectively reviewed 489 PDAC patients and compared the clinical characteristics and prognosis according to the opportunities for PDAC diagnosis. PDAC was diagnosed upon presentation of symptoms, such as pain and jaundice, in 318 cases including 151 DM patients, upon new-onset or exacerbation of long-standing DM in 53 asymptomatic patients, and upon incidental detection by medical check-up or follow-up/work-up of other diseases in 118 asymptomatic patients. Asymptomatic patients including those with DM had smaller tumors, earlier disease stage, and higher resectability rates than symptomatic patients. Asymptomatic patients diagnosed in association with DM had better prognosis (median survival time, 771 days) than those diagnosed due to symptoms (343 days, P < 0.001), and similar to those diagnosed by incidental detection (869 days). The survival advantage was not evident in symptomatic patients with DM-associated signs. In conclusion, patients diagnosed in association with DM at asymptomatic stages had better prognosis than those diagnosed with symptoms. DM-associated signs might provide a clue to the early diagnosis of PDAC among asymptomatic subjects.

Eucalyptus oil reduces allergic reactions and suppresses mast cell degranulation by downregulating IgE-FcεRI signalling.

Eucalyptus oil has been used since ancient times for its bactericidal, anti-inflammatory, analgesic and sedative effects. In recent years, the action of Eucalyptus oil has been scientifically proven, and there have been reports that Eucalyptus oil suppresses the production of chemokines, cytokines and lipid mediators in basophils, alveolar macrophages and monocytes. Based on this information, we aimed to verify whether Eucalyptus oil can be used for allergic dermatitis, the incidence of which has been increasing among human skin diseases. This effect was verified using a mouse IgE-mediated local allergic model. In conclusion, topical application of Eucalyptus oil suppressed oedema and vascular permeability enhancement due to IgE-mediated allergic on the skin. In addition, we also verified the degranuration of mast cells, which is a part of its action, and examined whether 1,8-cineole, which is the main component of Eucalyptus oil, suppresses the phosphorylation of PLCγ and p38 directly or indirectly. 1,8-cineole was found to suppress degranulation of mast cells.

Focal Parenchymal Atrophy and Fat Replacement Are Clues for Early Diagnosis of Pancreatic Cancer with Abnormalities of the Main Pancreatic Duct.

Pancreatic cancer is one of the most dangerous solid tumors, but its early diagnosis is difficult. The abnormality of the main pancreatic duct (MPD), such as a single localized stricture and upstream dilatation, might be useful in the early detection of pancreatic cancer. However, these findings are often observed in benign inflammatory cases. This study aimed to clarify whether early pancreatic cancer presenting MPD abnormalities has characteristic features different from those of benign cases. This is a single-center, retrospective study. We analyzed 20 patients who underwent pancreatectomy presenting with a single, localized MPD stricture without identifiable masses on imaging: 10 patients with pancreatic ductal adenocarcinoma (cancer group; 6 with stage 0 and 4 with stage I) and 10 patients with benign strictures (benign group; 8 with inflammation and 2 with low-grade pancreatic intraepithelial neoplasms). Pancreatectomy was performed in these benign cases because high-grade intraepithelial neoplasm was suspected. Although the proportion of patients with diabetes mellitus tended to be higher in the cancer group (6/10) than that in the benign group (1/10) (P = 0.058), other clinical characteristics were not different between the groups. Preoperative cytological malignancies were detected in four patients in the cancer group (4/10) but not in the benign group (P = 0.09). Focal parenchymal atrophy and fat replacement were more frequently detected on computed tomography in the cancer group (7/10) than in the benign group (1/10) (P = 0.02). In conclusion, focal parenchymal atrophy and fat replacement may provide clues for the early diagnosis of pancreatic cancer.

How to dissect the liver parenchyma: Excavation with cavitron ultrasonic surgical aspirator.

BACKGROUND: A large amount of blood flows in and out of the liver through the inflow system consisting of the portal vein and hepatic artery within the Glissonean cord and the outflow system constituted by the hepatic veins. METHODS: During liver parenchymal dissection, useful methods to maintain a dry operative field are to control the inflow system with the Pringle maneuver and the outflow system by managing the central venous pressure. Additionally, mature techniques of dissecting the liver parenchyma, which can prevent injury to the blood vessels and appropriately and promptly stop bleeding, are fundamental. Similar to archaeological excavation, in which buried remains are unearthed and exposed in intact form, the Glissonean cords and hepatic veins buried in the liver parenchyma should be exposed or isolated without causing injury to these structures during liver parenchymal dissection. RESULTS: The cavitron ultrasonic surgical aspirator (CUSA) is useful as a surgical device for excavation because it has multiple functions in one device. However, there have been no systematic guidelines on how to use it effectively during hepatectomy. CONCLUSION: We herein describe how to use the CUSA, based on our knowledge and experiences.

Basic knowledge of and a small trick for atraumatic needle driving in laparoscopic suturing.

Highlight Although recent advances in robotic surgery have enabled more precise movements of the needle driver, a sophisticated laparoscopic suturing technique is still desired. Honda and colleagues describe the basic knowledge of and a small but useful trick for atraumatic needle driving in laparoscopic suturing, based on mechanistic considerations.

Examination of a dose evaluation method for floor-mounted kV X-ray image-guided radiation therapy systems.

Floor-mounted kV X-ray image-guided radiation therapy systems (such as ExacTrac) are used to treat tumors in movable body regions such as the head and neck. ExacTrac requires exposure dose control based on image acquisition. However, placement of the aluminum plate perpendicular to the dosimeter is difficult due to the oblique X-ray beam path. This study provides an evaluation of the entrance surface, organ, and effective doses delivered to the head and neck during image-guided radiation therapy. A semiconductor detector (Unfors Xi) and radiophotoluminescent glass dosimeter (RPLD) were used as dosimeters with entrance surface dose calculation (Sdec) and exposure estimation (PCXMC) software. When the Unfors Xi was placed in front of the flat panel detector (FPD), an accurate entrance surface dose was obtained by considering the X-ray attenuation due to the influence of the distance from X-ray tube to FPD.The couch absorption was 32% and incident air kerma at the patient entrance point was 0.094 mGy for Unfors Xi. The entrance surface doses were 0.12 and 0.122 mGy for the Sdec and RPLD, respectively. The thyroid organ doses were 0.044 and 0.058 mGy for the RPLD and PCXMC, respectively. The effective doses of PCXMC for ExacTrac and cone-beam computed tomography were 0.0068 and 0.31 mSv, respectively. The exposure dose of ExacTrac was approximately 2% of that of cone-beam computed tomography. The results demonstrated that the proposed software-based method is effective for the assessment and management of ExacTrac exposure.