Tuberculous aneurysm diagnosed by CT-Guided biopsy after stent graft replacement: A case report.

A tuberculous aneurysm is an uncommon extrapulmonary tuberculosis and is usually fatal. The best way to treat it involves a combination of open surgery and medical treatment. However, it can be challenging to diagnose a tuberculous aneurysm. In this report, we describe a patient with a tuberculous aneurysm who was treated with stent-graft replacement and CT-guided biopsy for diagnosis, followed by nine months of anti-tuberculosis therapy. Despite one week of anti-tuberculous therapy, her fever persisted. A CT scan revealed new, well-defined nodules measuring 1-2mm in the lungs and hepatomegaly, indicating complications of miliary tuberculosis. After three weeks after the CT-guided biopsy, Mycobacterium tuberculosis grew from the arterial wall tissue, leading to the diagnosis of a tuberculous aneurysm complicated by miliary tuberculosis. The patient's aneurysm disappeared on follow-up CT scans, and the patient has been under observation for five years without a relapse. This rare case of tuberculous aneurysm can provide lessons for countries with a low prevalence of tuberculosis. This suggests the possibility of treatment with stent-graft replacement and anti-tuberculous medication and the usefulness of CT-guided biopsy for microbiological and pathological diagnosis.

Long-term prognosis after stapled and hand-sewn ileal pouch-anal anastomoses for familial adenomatous polyposis: a multicenter retrospective study.

PURPOSE: The long-term prognosis of stapled and hand-sewn ileal pouch-anal anastomoses in familial adenomatous polyposis patients in Japan remains unknown. This study aimed to compare the overall survival in familial adenomatous polyposis patients who underwent stapled or hand-sewn ileal pouch-anal anastomosis. METHODS: This multicenter retrospective study was conducted at 12 institutions in Shizuoka Prefecture, Japan. The clinical outcomes of 53 eligible familial adenomatous polyposis patients who underwent stapled (n = 24) and hand-sewn (n = 29) ileal pouch-anal anastomosis were compared. RESULTS: The median follow-up duration was 171.5 months. The incidence of adenoma in the remnant rectum or anal transitional zone and metachronous rectal cancer was significantly more common in stapled ileal pouch-anal anastomosis (adenoma: stapled, 45.8%, vs. hand-sewn, 10.3%, p = 0.005; metachronous rectal cancer: 29.2%, vs. none, p = 0.002). The number of deaths was remarkably higher in stapled ileal pouch-anal anastomosis (p = 0.002). Metachronous rectal cancer was the most common cause of death. Overall survival was worse in stapled ileal pouch-anal anastomosis than in hand-sewn ileal pouch-anal anastomosis (120 months, 90.7% vs. 96.6%; 240 months, 63.7% vs. 96.6%; p = 0.044). Cox regression analysis revealed the independent effects of preoperative advanced colorectal cancer and stapled ileal pouch-anal anastomosis on overall survival. CONCLUSION: Stapled ileal pouch-anal anastomosis negatively affected the overall survival of familial adenomatous polyposis patients. Therefore, hand-sewn ileal pouch-anal anastomosis is recommended for better prognosis in these patients.

[Ruptured Thoracic Aortic Aneurysm Treated with Total Arch Replacement and Direct Transaortic Thoracic Endovascular Aortic Repair].

Open stent grafting is an effective technique in surgery for treating-ruptured aortic aneurysms in the distal aortic arch, but it is not always applied as it depends on the shape of the aneurysm. In this case, the aneurysm was long in the distal aortic arch and sharply angulated into the descending aorta;thus, it was anticipated that an off-the-shelf open stent graft would not cover the ruptured area. Therefore, we used a stent graft device for thoracic endovascular aortic repair as an open stent and succeeded in saving the patient's life.

Long-term Safety and Efficacy of Benralizumab for Eosinophilic Granulomatosis with Polyangiitis Complicated with Severe Neuropathy.

The efficacy of benralizumab, as well as mepolizumab, to granulomatosis with polyangiitis (EGPA) involved with mononeuritis multiplex remains unclear. We experienced a case of EGPA presenting neuropathy with severe asthma. Muscle weakness due to neuropathy involved with gait disturbance was partly ameliorated by intravenous immunoglobulin therapy. Mepolizumab (100 mg/day) did not promote further improvement of neuropathy. However, the administration of benralizumab instead of mepolizumab improved neuropathy quickly and enabled walking alone. The efficacy of benralizumab for EGPA and its complication has been maintained for over four years. Benralizumab may be a possible treatment for EGPA presenting neuropathy with severe asthma.

A Tin Oxide-Coated Copper Foam Hybridized with a Gas Diffusion Electrode for Efficient CO2 Reduction to Formate with a Current Density Exceeding 1 A cm-2.

The electrochemical CO2 reduction reaction (CO2 RR) is a promising strategy for closing the carbon cycle. Increasing the current density ( J) for CO2 RR products is a critical requirement for the social implementation of this technology. Herein, nanoscale tin-oxide-modified copper-oxide foam is hybridized with a carbon-based gas-diffusion electrode (GDE). Using the resultant electrode, the Jformate is increased to -1152 mA cm-2 at -1.2 V versus RHE in 1 m KOH, which is the highest value for CO2 -to-formate electrolysis. The formate faradaic efficiency (FEformate ) reaches ≈99% at -0.6 V versus RHE. The achievement of ultra-high-rate formate production is attributable to the following factors: i) homogeneously-modified Sn atoms suppressing H2 evolution and ii) the hydrophobic carbon nanoparticles on GDEs penetrating the macroporous structure of the foam causing the increase in the thickness of triple-phase interface. Additionally, the FEformate remains at ≈70% under a high J of -1.0 A cm-2 for more than 20 h.

[Distal Stent Graft-induced New Entry after Total Arch Replacement for the Aortic Dissection:Report of a Case].

A 73-year-old man after total arch replacement with open stent graft (OSG) technique for Stanford type B aortic dissection was found to have expanding descending aortic aneurysm. Contrast-enhanced computed tomography (CT) showed distal stent graft-induced new entry (distal SINE). We successfully performed additional thoracic endovascular aortic repair (TEVAR). The determinants of distal SINE are reported to be excessive distal oversizing and spring back force on the distal end of the stent graft, which might make the stress for descending aorta. We also found that the angle between distal end of the stent graft and the horizontal line of the body was changed. The angle when distal SINE occurred was smaller than that of when it was placed. Appropriate size selection and positioning of stent graft might reduce the risk of distal SINE events.

Increased risk of obstetric complications in patients with adenomyosis: A narrative literature review.

Background: Reproductive-age women occasionally face the pathological condition of adenomyosis, which is often concurrent with endometriosis. It is believed that endometriosis and adenomyosis increases the risk of obstetric complications. Although new insights into the mechanism of obstetric complications due to endometriosis are emerging, there is little information on the etiology of adverse pregnancy outcomes in pregnant women with adenomyosis. Methods: We performed a literature review focusing on the pathophysiological pathways of obstetric complications in women with adenomyosis using currently available basic and clinical studies. We used the internet search engines PubMed and Google Scholar to search for studies published between January 2000 and June 2021. We carefully read pertinent sections within each document to ensure relevancy. Main findings: The prevalence of adverse pregnancy outcomes in women with adenomyosis is increased after adjusting for conceiving by assisted reproductive technology. Thus, adenomyosis emerges as a relevant factor associated with several obstetric complications such as preterm birth, preterm premature rupture of membranes, placental abruption, small for gestational age/fetal growth restriction, and preeclampsia. Conclusion: It is plausible that the impact of adenomyosis on pregnancy outcomes is not always the same; rather it is dependent on the degree of uterine involvement and subtypes.

D-dimer level significance for deep vein thrombosis screening in the third trimester: a retrospective study.

BACKGROUND: Venous thromboembolism often develops after surgery and childbirth, resulting in death in some cases. Although early deep vein thrombosis (DVT) detection can predict pulmonary thromboembolism, there is no early screening method for DVT in pregnant women. Lack of consensus regarding significance or setting and cut-off value interpretation of D-dimer levels further impedes venous thromboembolism screening in pregnant women. This study aimed to examine the utility of third-trimester serum D-dimer levels as a screening test for DVT during pregnancy and to determine the frequency of asymptomatic DVT using lower-limb compression ultrasonography. METHODS: This single-center retrospective study included 497 pregnant women who underwent elective cesarean section at term in our hospital between January 2013 and December 2019. Serum D-dimer levels were preoperatively measured at 32-37 weeks' gestation. The presence or absence of DVT in patients with serum D-dimer levels ≥ 3.0 µg/ml, the cut-off value, was examined using compression ultrasonography. In all patients, the presence or absence of clinical venous thrombosis (symptoms such as lower-limb pain, swelling, and heat sensation) was examined within 4 postoperative weeks. The Royal College of Obstetricians and Gynecologists Guideline 2015 was referred to determine risk factors for the onset of venous thrombosis during pregnancy. Among those, we examined the risk factors for DVT that result in high D-dimer levels during pregnancy. RESULTS: The median age and body mass index were 35 (20-47) years and 21.2 (16.4-41.1) kg/m2, respectively. Further, the median gestational age and D-dimer levels were 37 weeks and 2.1 (0.2-16.0) µg/ml, respectively. Compression ultrasonography was performed on 135 (26.5%) patients with a D-dimer level ≥ 3.0 µg/ml, with none of the patients showing DVT. All patients were followed up for 4 postoperative weeks, with none presenting with venous thromboembolism. Multivariate analysis showed that hypertensive disorders of pregnancy are an independent risk factor for venous thromboembolism that causes high D-dimer levels (odds ratio: 2.48, 95% confidence interval: 1.05-6.50, P = 0.04). CONCLUSION: There may be low utility in screening for DVT using D-dimer levels in the third trimester. Further, prepartum asymptomatic DVT has a low frequency, indicating the low utility of compression ultrasonography. TRIAL REGISTRATION: Institutional Review Board of Tottori University Hospital (IRB no. 20A149 ).

Defining the treatment strategy for uncomplicated appendicitis based on patient satisfaction feedback: A cross-sectional study.

BACKGROUND: Two surgical strategies are available for appendicitis: emergency laparoscopic appendectomy and interval laparoscopic appendectomy. However, timing of surgical intervention remains debatable. This study aimed to compare the surgical outcomes of emergency laparoscopic appendectomy and interval laparoscopic appendectomy and conduct a questionnaire survey to investigate the use of emergency laparoscopic appendectomy and patient satisfaction with regard to treatment. METHODS: We included 162 patients who underwent laparoscopic appendectomy at our hospital. Outcomes were assessed by operation time, blood loss, postoperative fasting time, length of hospital stay, and complication rate. Patient satisfaction was measured by questionnaire addressing degree of satisfaction, presurgery anxiety, and length of hospital stay. RESULTS: Of 162 patients, 74 (46%) and 88 (54%) received emergency and interval laparoscopic appendectomy, respectively. No significant difference was observed in the operation time, blood loss, length of hospital stay, or complication rate. Among 66 patients who responded to the questionnaire (28 emergency, 38 interval), a significant difference was observed only in the degree of satisfaction regarding the timing of the surgical intervention (p = 0.04). CONCLUSION: Surgical outcomes of emergency and interval appendectomy were equivalent; however, patient satisfaction favored emergency appendectomy, suggesting it is a preferable approach for the treatment of uncomplicated appendicitis.

Prognostic impact of polypharmacy by drug essentiality in patients on hemodialysis.

Although polypharmacy is common among patients on hemodialysis (HD), its association with prognosis remains unclear. This study aimed to elucidate the association between the number of prescribed medicines and all-cause mortality in patients on HD, accounting for essential medicines (i.e., antihypertensives, antidiabetic medicines, and statins) and non-essential medicines. We evaluated 339 patients who underwent maintenance HD at Nagasaki Renal Center between July 2011 and June 2012 and followed up until June 2021. After adjusting for patient characteristics, the number of regularly prescribed medicines (10.0 ± 4.0) was not correlated with prognosis (hazard ratio [HR]: 1.01, 95% confidence interval [CI] 0.97-1.05, p = 0.60). However, the number of non-essential medicines (7.9 ± 3.6) was correlated with prognosis (HR: 1.06, 95% CI 1.01-1.10, p = 0.009). Adjusting for patient characteristics, patients who were prescribed more than 10 non-essential medicines were found to have a significantly higher probability of mortality than those prescribed less than five non-essential medicines, with a relative risk of 2.01 (p = 0.004). In conclusion, polypharmacy of non-essential medicines increases the risk of all-cause mortality in patients on HD. As such, prescribing essential medicines should be prioritized, and the clinical relevance of each medicine should be reviewed by physicians and pharmacists.

[Pharmacological characteristics and clinical study results of Pemigatinib (Pemazyre® Tablets), a selective fibroblast growth factor receptor (FGFR) inhibitor].

Pemigatinib (Pemazyre® Tablets 4.5 mg) is a novel fibroblast growth factor receptor (FGFR) inhibitor, created by Incyte Corporation. The product was approved in March 2021 and was launched in June 2021 for the treatment of patients with locally advanced or metastatic biliary tract cancer (BTC) with a fibroblast growth factor receptor 2 (FGFR2) fusion or rearrangement that has progressed after at least one prior line of systemic therapy. Pemigatinib was shown to selectively inhibit kinase activity of FGFR1～3 (IC50; 0.39～1.2 nM). In cultured cells, pemigatinib inhibited the phosphorylation of FGFR1 and its downstream signals, ERK1/2 and STAT5 in a concentration-dependent manner. Pemigatinib also potently inhibited the growth of various types of cell lines with FGFR 1～3 gene alteration. Pemigatinib was shown to induce concentration-dependent tumor regression in a tumor xenograft model mice in which tumor tissue sections from patients with cholangiocarcinoma (CCA) harboring FGFR2 gene fusions were transplanted. Pemigatinib was well tolerated in Japanese and overseas Phase1 studies (INCB 54828-101 and 202). In the global phase2 study (INCB 54828-202) conducted in CCA patients with FGFR2 gene fusions or rearrangements, significant improvement in the overall response rate was observed. Although several adverse reactions were observed which was based on the mechanism of action of pemigatinib, the safety profile and management of the adverse reactions were favorable. Pemigatinib is expected to contribute to second-line drug treatment after failure of standard therapies in biliary tract cancer.

The impact of muscle mass loss and deteriorating physical function on prognosis in patients receiving hemodialysis.

Muscle mass loss and worsening physical function are crucial issues in patients receiving hemodialysis (HD). However, few studies have investigated the association between temporal changes in muscle mass and physical function in a large number of HD patients. We examined 286 patients receiving HD (males, 58%; age, 66.8 ± 13.0 years) at a single center, and calculated the percent changes in psoas muscle mass index (%PMI) using computed tomography over two screenings, once per year (July 2011-June 2013). Physical function was evaluated using the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) (range 0-4). The observation period was from July 2012 to June 2021. The median %PMI was -9.5%, and those with the lowest quartile of %PMI (< -20.5%) showed a significantly poor prognosis compared with other patients (p < 0.001). Multivariable logistic regression analysis revealed that these patients tended to have decreased physical function (ECOG-PS 2-4) [odds ratio (OR): 2.46, p < 0.001] and albumin levels (OR: 0.22, p = 0.007). Multiple-factor-adjusted Cox regression analyses showed that %PMI (hazard ratio: 0.99, p = 0.004) and each ECOG-PS stage (1-4 vs. 0) (p < 0.01) were associated with mortality. Augmenting physical activities in daily life and serum albumin levels should be considered to maintain muscle mass and improve the prognosis of patients receiving HD.

Hemodialysis Patient with Diffuse Liver Calcification After Septic Shock.

BACKGROUND Calcification in arteries is sometimes observed in patients undergoing hemodialysis; however, ectopic calcification in other organs is uncommon. In particular, diffuse liver calcification is very rare. We report a case of rapidly developing diffuse liver calcification in a patient undergoing hemodialysis. CASE REPORT An 82-year-old woman started hemodialysis because of diabetic nephropathy, and her renal function worsened due to acute coronary syndrome. Percutaneous coronary intervention was conducted, and she was referred to our hospital. However, she subsequently contracted various infections, including a urinary tract infection and pneumonia. On day 43 of hospitalization, she developed septic shock and liver dysfunction due to catheter-induced infection. Although she did not have any medical history of liver disease, hypoperfusion of the liver resulted in liver dysfunction, and a computed tomography scan conducted 3 months later showed diffuse calcification in her liver. Despite recovering from septic shock, she ultimately died of multiple organ failure 21 months after admission to our hospital. CONCLUSIONS Diffuse liver calcification is extremely rare; however, it can be observed in patients undergoing hemodialysis who experience liver hypoperfusion. The precise mechanisms underlying this disorder remain unknown, but a critically ill status and specific characteristics of hemodialysis patients may play important roles in liver calcification.

Malignant solitary fibrous tumor of the pancreas: a case report.

BACKGROUND: Solitary fibrous tumors (SFTs) are rare tumors, mostly derived from connective tissue mesenchymal cells that arise from the pleura. There are very few reports of primary pancreatic SFT. Preoperative diagnosis is difficult owing to the lack of distinctive radiological findings. We report a case of pancreatic SFT with particularly rare malignant findings. CASE PRESENTATION: A 60-year-old man was referred to the hospital because of a right upper quadrant mass and abnormal liver function test results. Contrast-enhanced computed tomography (CT) showed a well-defined enhanced tumor measuring approximately 8 cm in the pancreatic head. Magnetic resonance imaging (MRI) showed T1WI hypointensity, T2WI hyperintensity, and DWI hyperintensity. The main pancreatic duct and common bile duct were dilated owing to obstruction by the tumor. The following tumor markers were mildly elevated: carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), SPan-1, and DUPAN-2. The histological diagnosis obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was negative for pancreatic ductal carcinoma, malignant lymphoma and neuroendocrine tumor, suggesting the possibility of mesenchymal tumor, but the diagnosis was not confirmed. The patient was judged suitable for surgery and underwent subtotal stomach-preserving pancreatoduodenectomy with D2 lymph node dissection. On histopathological examination of the resected specimen, infiltrating spindle-shaped cells had proliferated, containing numerous mitotic figures, with necrotic findings inside the tumor. Immunostaining was positive for cluster of differentiation-34 (CD34), B cell CLL/lymphoma-2 (Bcl-2), and signal transducer and activator of transcription (STAT6). On the basis of these findings, a diagnosis of malignant pancreatic SFT was made. The patient remains free of recurrent disease after 12 months of follow-up without adjuvant therapy and he is being carefully followed up as an outpatient. CONCLUSIONS: We experienced a case of malignant pancreatic head SFT. Immunohistochemical staining of the extracted specimens was useful for diagnosis.

Critical left coronary main trunk stenosis, chronic occluded right coronary artery, left subclavian artery occlusion, severe aortic regurgitation and porcelain aorta in a patient with aortitis.

BACKGROUND: Coronary involvement is rare but can be critical in patients with aortitis. Although cardiac ischemia can be resolved by coronary artery bypass grafting (CABG), patients complicated with cardiac ischemia, calcified aorta, and valve insufficiency pose difficult problems for surgeons. CASE PRESENTATION: A 71-year-old woman was referred to our institution because of unstable angina. She had been previously diagnosed with aortitis and left subclavian artery occlusion. Contrast-enhanced computed tomography revealed severe left coronary main trunk stenosis, right coronary artery occlusion, and porcelain aorta. Ultrasonic echocardiogram showed severe aortic regurgitation. We performed emergent coronary artery bypass grafting, aortic valve replacement and ascending aorta replacement under hypothermic circulatory arrest. CONCLUSIONS: The technique of circumferential calcified intimal removal and reinforcement with felt strips was effective for secure anastomosis. Unilateral cerebral perfusion from the right subclavian artery enabled good visualization and sufficient time to perform distal anastomosis.

Incidental retroaortic innominate vein in a patient with acute aortic dissection.

BACKGROUND: Retroaortic innominate vein is a rare anomaly. It has been reported in patients with congenital anomalies such as Tetralogy of Fallot or right aortic arch. However, isolated retroaortic innominate vein is quite rare. CASE PRESENTATION: A 63-year-old man was transferred to our institution because of Stanford type A acute aortic dissection. Incidentally, we noticed that the left innominate vein coursed under the aortic arch and was directed into the superior vena cava on computed tomography. We performed emergent hemiarch replacement. CONCLUSIONS: Attention must be paid to the cannulation site for venous uptake and the method of myocardial protection.

Aorto-carotid bypass for type A acute aortic dissection complicated with carotid artery occlusion: no touch until circulatory arrest.

The surgical management for type A acute aortic dissection complicated with carotid artery occlusion remains controversial. Between December 2012 and June 2017, 127 patients who presented with type A acute aortic dissection were operated on in our hospital. Of this group, nine (7.08%) patients had cerebral malperfusion due to carotid artery occlusion. The site of occlusion was innominate artery (n = 5) or right carotid artery (n = 4). Preoperative neurological symptoms were left hemiplegia (n = 1), left hemiparesis (n = 3) and seizure (n = 2). Preoperative consciousness level was Japan Coma Scale 2 (n = 6), 20 (n = 2), or 200 (n = 1). The procedure consisted of hemiarch replacement (n = 4) or total arch replacement (n = 5). Aorto-carotid bypass was performed in all patients under hypothermic circulatory arrest. The time from onset of symptoms to operating room was 7.2 ± 2.4 h. Hospital mortality was 0%. Left hemiplegia and left hemiparesis improved significantly. Japan Coma Scale was 0 in all patients at discharge. Overall survival at 24 months after operation was 100%. Aorto-carotid artery bypass for type A acute aortic dissection with carotid artery occlusion is the treatment of choice in these high-risk patients. Our strategy of 'no touch until circulatory arrest' may contribute to neurological improvement.

Ventriculitis after emergent arch aneurysm surgery.

A 72-year-old man was referred to our institution because of an arch aneurysm and acute aortic dissection (thrombosed Stanford type A). Anti-impulse therapy was initiated. He developed a high fever after admission. Blood culture was negative. Five days after admission, he developed back pain. Thoracoabdominal computed tomography revealed a new low-density area from the distal arch to the descending aorta. We performed emergent total arch replacement. Although we discontinued all sedative drugs after surgery, coma continued. Brain magnetic resonance imaging with diffusion-weighted imaging revealed ventriculitis with brain infarction. After antimicrobial therapy was started, his consciousness level improved. Ventriculitis should be suspected when disturbance of consciousness continues longer than we predict after emergent arch aneurysm surgery. Delay in diagnosis can lead to a life-threatening condition.

A rectal neuroendocrine tumor in a patient with Crohn's disease: a case report and literature review.

Crohn's disease is recognized to increase the risk of gastrointestinal malignances. Adenocarcinoma is the most common malignancy in these patients. Association between Crohn's disease and adenocarcinoma in the small intestine has already been established, however, the association between neuroendocrine tumor and Crohn's disease remains uncertain. We report a 39-year-old man with Crohn's disease, who was diagnosed with NET in the rectum. He had suffered from fever and anal pain due to the anal fistula and abscess. The disease state was considered to be resistant to medical treatment. He underwent total proctocolectomy, small bowel resection, anal fistula drainage with ileostomy. Postoperative histology revealed a neuroendocrine tumor in the rectum. His postoperative course was uneventful, and he followed a good course under treatment with infliximab and mercaptopurine hydrate. This case highlights the need of careful observation of resected specimens in light of the possibility of NET, especially those with anal disorders.