Acute pancreatitis as a rare complication of leptospirosis: A case report and literature review.

Leptospirosis is a zoonotic disease. We present a case of acute pancreatitis associated with leptospirosis. An 88-year-old woman was admitted to the hospital with high fever and severe myalgia of the lower extremities. Based on the clinical presentation, hepatic dysfunction with a mild increase in bilirubin, renal dysfunction, and life history, the possibility of leptospirosis was considered. Plain computed tomography of the trunk on admission revealed no special findings. Appropriate antimicrobial therapy was administered at an early stage. After treatment initiation, the clinical symptoms and blood test abnormalities began to improve, and the patient appeared to be doing well. Although no abdominal or back pain was consistently noted during hospitalization, the serum amylase level increased over time; therefore, the patient underwent another computed tomography scan on the ninth day. Acute pancreatitis, which was absent upon admission, was noted. Appropriate treatment for pancreatitis was administered, and the patient was discharged. A subsequent serum antibody test confirmed the diagnosis of leptospirosis. Herein, we also summarized previous cases of acute pancreatitis associated with leptospirosis. The time of onset for pancreatitis was inconsistent, and there were a few cases of pancreatitis without abdominal or back pain. In contrast, serum amylase or lipase levels were elevated in all patients, which could be an important trigger for suspected complications of pancreatitis. When leptospirosis is suspected, complications of pancreatitis should always be considered, even in the absence of apparent abdominal pain. Regular monitoring of pancreatic enzymes such as amylase and lipase is recommended.

The factors influencing long-term outcomes of stenting for malignant colorectal obstruction in elderly group in community medicine.

PURPOSE: Malignant bowel obstruction is a complication of colorectal carcinoma or metastasis from other carcinoma, and it causes significant damage on the condition of elderly patients; however, the self-expandable metallic stents (SEMSs) have been effectively used either for palliation or for bridging to the surgical procedure for this condition. The aim of this study was to investigate the factors influencing long-term outcomes of old-aged patients with SEMS for large bowel obstruction to develop the strategy for those patients in the community medicine. METHODS: We performed a retrospective review of 42 patients with a median age of 83.0 years (range, 65-99 years), who underwent SEMS placement for malignant colorectal obstruction between 2006 and 2015 in our hospital. Univariate and multivariate logistic regressions were performed on data from the patients to assess the factors affecting 6-month survival without stent dysfunction. RESULTS: The study population comprised 24 females (57.1%) and 18 males (42.9%). Of these, 38 patients (90.5%) received SEMS as palliation, whereas 4 patients (9.5%) underwent subsequent surgery. SEMSs were successfully inserted in 97.6% of patients. The median duration of follow-up was 205.0 days (range, 20-1377 days). On multivariate analysis, shorter stents (< 10 cm) yielded better outcomes than longer stents (≥ 10 cm) (P = 0.041), and the Cox proportional hazard model also indicated that shorter stents (P = 0.036) predicted longer event-free survival. CONCLUSIONS: Elderly patients with malignant bowel obstruction receiving shorter stents had longer event-free survival after stenting with better general condition.

Myocardial triglyceride content in patients with left ventricular hypertrophy: comparison between hypertensive heart disease and hypertrophic cardiomyopathy.

Proton magnetic resonance spectroscopy (1H-MRS) enables the assessment of myocardial triglyceride (TG) content, which is reported to be associated with cardiac dysfunction and morphology accompanied by metabolic disorder and cardiac hemodynamic status. The clinical usefulness of myocardial TG content measurements in patients with left ventricular hypertrophy (LVH) has not been fully investigated. We examined whether myocardial TG content assessed by 1H-MRS was useful for diagnosis in patients with LVH. To quantify myocardial TG content, we conducted 1H-MRS in 35 subjects with LVH. Left ventricular function was measured by cardiac magnetic resonance imaging. Patients were assigned to a hypertensive heart disease (HHD, n = 10) or hypertrophic cardiomyopathy (HCM, n = 25) group based on the histology and/or late gadolinium enhancement pattern. The myocardial TG content was significantly higher in the HHD group than in the HCM group (2.14 ± 1.29 vs. 1.09 ± 0.72 %, P < 0.001). Myocardial TG content were significantly and negatively correlated with LV mass (r = -0.41, P < 0.04) and stroke volume (r = -0.64, P < 0.05) in the HCM group and HHD group, respectively. In a multivariate analysis, LV mass volume and diagnosis of HCM or HHD were independent factors of the myocardial TG content. The results suggest that myocardial metabolism may differ between HCM and HHD patients and that measurement of myocardial TG content by 1H-MRS may be useful for evaluating the myocardial metabolic features of LVH.

Significance of Coronary Artery Disease and Left Ventricular Afterload in Unoperated Asymptomatic Aortic Stenosis.

BACKGROUND: Because the covariates of cardiovascular events in unoperated patients with asymptomatic aortic stenosis (AS) have not been adequately evaluated, we aimed to identify them. METHODS AND RESULTS: A total of 230 patients with asymptomatic severe AS were retrospectively enrolled. The patients were divided into 2 groups based on aortic valve replacement (AVR) after enrollment: a non-AVR group (n=112), and an AVR group (n=118). The primary clinical endpoint was cardiovascular events, which were defined as cardiovascular death or hospitalization. Coronary artery disease [hazard ratio (HR): 3.62, 95% confidence interval (CI): 1.585-8.245, P<0.01] and high valvulo-arterial impedance (HR: 3.08, 95% CI: 1.261-7.532, P<0.05) were identified as independent covariates of cardiovascular events in the non-AVR group. The relative risk of cardiovascular events rose with an increase in the number of risk factors (P<0.0001). CONCLUSIONS: In unoperated patients with asymptomatic AS, the presence of coronary artery disease and increased global left ventricular afterload may be associated with a poor prognosis.

Clinical benefits of bortezomib-containing regimens for newly diagnosed AL amyloidosis with severe cardiac impairment.

Cardiac amyloid light-chain amyloidosis (AL amyloidosis) is a rare disease with a very poor prognosis, associated with plasma cell dyscrasias such as monoclonal gammopathy of undetermined significance and multiple myeloma. Though bortezomib-containing regimens have achieved high hematologic response rates, there are still few reports describing the outcomes of Japanese patients. Six patients with severe cardiac AL amyloidosis were treated with bortezomib-containing regimens. Involved free light chain (iFLC) decreased immediately in most of these cases. However, the condition of heart failure and N-terminal pro-B-type natriuretic peptide (NT-proBNP) worsened in the early phase of this treatment and then improved several months later. At 29 months, the median duration of follow-up (2-47months), all patients remain alive except one who died of sudden cardiac arrest. Bortezomib-containing regimens are considered to be among the effective treatments for severe cardiac AL amyloidosis.

Coronary microvascular function is independently associated with left ventricular filling pressure in patients with type 2 diabetes mellitus.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is known as an early marker of myocardial alterations in patients with diabetes. Because microvascular disease has been regarded as an important cause of heart failure or diastolic dysfunction in diabetic patients, we tested the hypothesis that coronary flow reserve (CFR), which reflects coronary microvascular function, is associated with LV diastolic dysfunction in patients with type 2 diabetes. METHODS: We studied asymptomatic patients with type 2 diabetes but without overt heart failure. Transthoracic Doppler echocardiography was performed that included pulsed tissue Doppler of the mitral annulus and CFR of the left anterior descending artery (induced by adenosine 0.14 mg/kg/min). The ratio of mitral velocity to early diastolic velocity of the mitral annulus (E/e') was used as a surrogate marker of diastolic function. We also evaluated renal function, lipid profile, parameters of glycemic control and other clinical characteristics to determine their association with E/e'. Patients with LV ejection fraction <50%, atrial fibrillation, valvular disease, regional wall motion abnormality, renal failure (serum creatinine >2.0 mg/dl) or type 1 diabetes were excluded. Patients with a CFR <2.0 were also excluded based on the suspicion of significant coronary artery stenosis. RESULTS: We included 67 asymptomatic patients with type 2 diabetes and 14 non-diabetic controls in the final study population. In univariate analysis, age, presence of hypertension, LV mass index, estimated glomerular filtration rate and CFR were significantly associated with E/e'. Multivariate analysis indicated that both LV mass index and CFR were independently associated with E/e'. In contrast, there were no significant associations between parameters of glycemic control and E/e'. CONCLUSIONS: CFR was associated with LV filling pressure in patients with type 2 diabetes. This result suggests a possible link between coronary microvascular disease and LV diastolic function in these subjects.

Early hemodynamic performance of the trifecta bioprosthetic valve in patients with aortic valve disease.

BACKGROUND: The Trifecta valve (St Jude Medical) is a novel supra-annular aortic bioprosthesis designed to improve hemodynamic performance. We hypothesized that the Trifecta may offer better hemodynamic performance in Japanese patients, in whom the annulus is smaller, compared with Western populations. We compared the early results of hemodynamic performance between the Trifecta and the Magna (Edwards Lifescience) valves at our institution. METHODS AND RESULTS: The Trifecta was implanted in 33 patients and the Magna was implanted in 41 patients who had aortic valve disease. Postoperative echocardiography was performed just before discharge, and the mean pressure gradient (MPG), effective orifice area (EOA) index and energy loss coefficient (ELCo) index were compared between the 2 groups. The average prosthesis size was similar between the 2 groups (21.1 vs. 21.3mm). The Trifecta group had a significantly lower MPG (P=0.001) and larger EOA index and ELCo index than the Magna group (P<0.001 for both). On multivariate linear regression analysis, use of the Trifecta was the strongest independent determinant of postoperative MPG, EOA and ELCo index. CONCLUSIONS: The Trifecta valve provides excellent early postoperative hemodynamic performance in Japanese patients. Patients with a small annulus size relative to body size may benefit more from the Trifecta in terms of postoperative hemodynamic performance.

Prognostic value of coronary flow reserve assessed by transthoracic Doppler echocardiography on long-term outcome in asymptomatic patients with type 2 diabetes without overt coronary artery disease.

BACKGROUND: Cardiovascular risk stratification of asymptomatic diabetic patients is important and remains a difficult clinical problem. Our aim was to test the hypothesis that coronary flow reserve (CFR) assessed by noninvasive transthoracic Doppler echocardiography predicts prognosis in those patients. METHODS: From February 2002 to January 2005, we evaluated 135 consecutive asymptomatic patients (74 male; mean age, 63 ± 9 years) with type 2 diabetes without a history of coronary artery disease. Adenosine triphosphate (0.14 mg/kg/min) stress Doppler echocardiography was performed to evaluate CFR of the left anterior descending artery. Patients with a CFR < 2.0 were also excluded based on the suspicion of significant coronary artery stenosis in the left anterior descending artery. RESULTS: There were 111 patients (60 male; mean age, 64 ± 9 years) enrolled. During a median follow-up of 79 months, 20 events (5 deaths, 7 acute coronary syndromes, 8 coronary revascularizations) occurred. The optimal cut-off value of CFR to predict events was 2.5 (area under the receiver-operating characteristic curve = 0.65). Multivariate analysis showed that the independent prognostic indicators were male gender (p < 0.05) and a CFR < 2.5 (p < 0.01). Kaplan-Mayer analysis revealed that the event rate was significantly higher (log-lank, p < 0.01) in patients with CFR < 2.5 than in those with CFR ≥ 2.5. CONCLUSIONS: CFR obtained by transthoracic Doppler echocardiography provides independent prognostic information in asymptomatic patients with type 2 diabetes without overt coronary artery disease. Patients with CFR < 2.5 had a worse long-term outcome.

Influencing factors on cardiac structure and function beyond glycemic control in patients with type 2 diabetes mellitus.

BACKGROUND: We hypothesized that clinical factors other than glycemic control may influence abnormal cardiac function in patients with type 2 diabetes mellitus (T2DM). We aimed to investigate the independent factors for abnormal cardiac function among clinical factors in T2DM. METHODS: We studied 148 asymptomatic patients with T2DM without overt heart disease. Echocardiographic findings were compared between diabetic patients and 68 age-matched healthy subjects. Early (E) and late (A) diastolic mitral flow velocity and early diastolic mitral annular velocity (e') were measured for assessing left ventricular (LV) diastolic function. We evaluated insulin resistance, non-esterified fatty acid, high-sensitive CRP, estimated glomerular filtration rate, waist/hip ratio, abdominal visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT) and other clinical characteristics in addition to glycemic control. VAT and SAT were quantified by computed tomography. RESULTS: In T2DM, E/A and e' were significantly lower, and E/e', left atrial volume and LV mass were significantly greater than in control subjects. In multivariate liner regression analysis, VAT was an independent determinant of left atrial volume (ß =0.203, p=0.011), E/A (ß =-0.208, p=0.002), e' (ß =-0.354, p<0.001) and E/e' (ß=0.220, p=0.003). Age was also an independent determinant, whereas fasting plasma glucose and hemoglobin A1c levels were not. In addition to systolic blood pressure, waist-hip ratio (ß=0.173, p=0.024) and VAT/SAT ratio (ß=0.162, p=0.049) were independent determinants of LV mass. CONCLUSION: Excessive visceral fat accompanied by adipocyte dysfunction may play a greater role than glycemic control in the development of diastolic dysfunction and LV hypertrophy in T2DM.

Duodenal Diverticular Bleeding Treated with Endoscopy or Transcatheter Arterial Embolization: A Report of Two Cases and a Literature Review.

Duodenal diverticular bleeding (DDB) is extremely rare. We herein report 2 life-threatening cases of DDB successfully treated with endoscopy or transcatheter arterial embolization (TAE) and review 13 cases of DDB reported from Japan. When upper gastrointestinal bleeding of unknown origin is encountered in middle-aged or older adults, DDB should be included in the differential diagnosis. DDB often causes massive bleeding. It is therefore important to judge which is safer and more effective, endoscopy or TAE, based on the general condition of the patient. In addition, it is critical to attempt hemostasis via various strategies, including different gastroscopes and hemostatic devices.

Effectiveness and safety of lubiprostone after switching from stimulant laxatives in elderly patients with chronic constipation.

Background and Aim: Stimulant laxatives may cause electrolyte abnormalities, dehydration, and abdominal pain; their long-term use can lead to tolerance and subsequent refractory constipation. We investigated the effectiveness, safety, and quality of life after switching from stimulant laxatives to lubiprostone in elderly patients with chronic constipation (CC). Methods: This multicenter, interventional, open-label, single-arm, before-and-after comparison study enrolled 99 Japanese patients aged 65-90 years with CC who took stimulant laxatives for ≥2 weeks prior to switching to lubiprostone monotherapy. Results: The mean ± SD spontaneous defecations at Week 1 of 7.8 ± 6.2 times/week was not significantly different from that at baseline (8.3 ± 4.7). Spontaneous defecations were significantly reduced at Weeks 2 (-1.5 ± 4.0, P < 0.001) and 4 (-1.5 ± 3.7, P < 0.001). The Bristol Stool Form Scale score did not change from baseline (4.7 ± 0.9) at Weeks 1 (4.5 ± 1.3) or 4 (4.3 ± 1.3), but it did at Week 2 (4.3 ± 1.5, P < 0.05). The Patient Assessment of Constipation Quality of Life questionnaire score increased (0.36 ± 0.07, P < 0.001) after 28 days. Nausea was the only symptom that worsened from baseline and was the most frequently reported adverse drug reaction (15.2%). Conclusion: Switching to lubiprostone monotherapy for CC was not associated with significant concerns in short-term spontaneous defecation frequency and safety, but it might affect the efficacy and patient quality of life over 2 weeks. Careful treatment strategies facilitating gradual switching to lubiprostone monotherapy may be needed in patients using stimulant laxatives.

The cortical representation of simple mathematical expressions.

Written mathematical notation conveys, in a compact visual form, the nested functional relations among abstract concepts such as operators, numbers or sets. Is the comprehension of mathematical expressions derived from the human capacity for processing the recursive structure of language? Or does algebraic processing rely only on a language-independent network, jointly involving the visual system for parsing the string of mathematical symbols and the intraparietal system for representing numbers and operators? We tested these competing hypotheses by scanning mathematically trained adults while they viewed simple strings ranging from randomly arranged characters to mathematical expressions with up to three levels of nested parentheses. Syntactic effects were observed in behavior and in brain activation measured with functional magnetic resonance imaging (fMRI) and magneto-encephalography (MEG). Bilateral occipito-temporal cortices and right parietal and precentral cortices appeared as the primary nodes for mathematical syntax. MEG estimated that a mathematical expression could be parsed by posterior visual regions in less than 180 ms. Nevertheless, a small increase in activation with increasing expression complexity was observed in linguistic regions of interest, including the left inferior frontal gyrus and the posterior superior temporal sulcus. We suggest that mathematical syntax, although arising historically from language competence, becomes "compiled" into visuo-spatial areas in well-trained mathematics students.

Transbrachial intra-aortic balloon pumping for a patient with fulminant myocarditis.

A 57-year-old man with acute myocarditis was transferred to our hospital from a local clinic. The patient experienced unexpected sudden cardiac arrest 16 h after admission. Mechanical cardiopulmonary support was started using percutaneous cardiopulmonary support, intra-aortic balloon pumping (IABP), continuous hemodialysis filtration, and temporary cardiac pacing with percutaneous cannulation of the femoral vessels. Hematoma developed at the IABP insertion site on the 5th day after admission. The IABP was removed, and another IABP system was inserted via the left brachial artery. The patient's condition improved, and the IABP was removed on the 9th day after admission. The remainder of the patient's in-hospital treatment was uneventful, and he showed near-normal left ventricular systolic function 1 year after discharge.

A difficult-to-diagnose case of Borrmann type IV gastric cancer with marked transverse colon stenosis.

We report a difficult-to-diagnose case of Borrmann type IV gastric cancer with poor typical findings and marked colonic stenosis in a 47-year-old man and present a literature review.

[Analysis of postoperative pulmonary complications after esophagectomy for esophageal cancer].

We examined factors contributing to an onset of postoperative pulmonary complications following esophagectomy for esophagus cancer. One hundred thirty-two cases of the resected esophageal cancer were studied. We considered the relationship between preoperative patient factors, operative factors, clinical stage factors and postoperative pulmonary complications. Postoperative pulmonary complication was observed in 27 cases (20%). The incidence of postoperative pulmonary complications was significantly higher in patients aged 70 and above and those with a preoperative serum albumin value of less than 4 .0 g/dL. Additionally, these two factors were correlated with an onset of postoperative pulmonary complications in multivariate analyses. A decrease of preoperative serum albumin value was reflecting the chronic poor nutritional condition. Moreover, it was possible that poor nutritional condition served as a prognostic factor of postoperative complications in relation to reduction of cellular immunity. The results indicated that there was a possibility of decreasing an onset of postoperative pulmonary complications using various nutrition managements before operations.

Stimulus-contrast-induced biases in activation order reveal interaction between V1/V2 and human MT+.

The luminance contrast of a visual stimulus is known to modulate the response properties of areas V1 and the human MT complex (hMT+), but has not been shown to modulate interactions between these two areas. We examined the direction of information transfer between V1/V2 and hMT+ at different stimulus contrasts by measuring magnetoencephalographic (MEG) responses to moving and stationary stimuli presented centrally or peripherally. To determine the direction of information flow, the different response latencies among stimuli and hemispheres in V1/V2 was compared with those of hMT+. At high contrast, responses to stimulus motion and position began in V1/V2, and were followed in hMT+ with a delay between 34 and 55 ms. However, at low contrast, lateralized responses in hMT+ came first, with those in V1/V2 lagging with a delay of 27 ms. Also, at high contrast, stationary stimuli produced greater responses than motion stimuli in V1/V2, while the reverse was true in hMT+, whose response lagged behind the initial response in V1/V2. The same activation order was found using Mutual Information Analysis of the response variances for each condition. Here, the response variances in hMT+ mimicked and trailed those of V1/V2 at high contrast, whereas the reverse was true at low contrast. Such consistent interactions found using two different methodologies strongly supports a processing link between these two areas. The results also suggest that feedback from hMT+ for low-contrast stimuli compensates for unresolved processing in V1/V2 when the input of a visual image is weak.

Endoscopic ultrasound-guided internalization of a pancreaticocutaneous fistula utilizing a balloon-target technique: A case report.

RATIONALE: Endoscopic ultrasound (EUS)-guided treatment has been recently described for internalizing refractory pancreaticocutaneous fistulas (PCFs). However, the existing techniques are limited because of the difficulty in accessing nondilated pancreatic ducts or fistulas. In an attempt to overcome this limitation, we present a case where a EUS-guided intervention utilizing a balloon-target technique was employed to internalize a PCF into the stomach. PATIENT CONCERNS: A 78-year-old woman underwent percutaneous drainage and 4 percutaneous endoscopic necrosectomies for walled-off pancreatic necrosis (WOPN) after severe acute pancreatitis due to choledocholithiasis. Although the WOPN was resolved, refractory PCFs remained. DIAGNOSIS: Pancreaticocutaneous fistulas. INTERVENTIONS: An echoendoscope was introduced into the stomach, but the narrow PCF lumen made visualization of the fistula by EUS difficult. Subsequently, a balloon catheter was percutaneously inserted into the fistula, and then the inflated balloon was visualized by EUS from the stomach. The balloon was punctured with a 19-gauge fine needle through the posterior wall of the upper body of the stomach (balloon-target technique). A guidewire was then passed through the fistula to the outside of the body through the EUS scope. After dilating the gastro-fistula space with an 8-mm balloon dilation catheter, a 7-French double pigtail catheter was placed from the stomach into the PCF. OUTCOMES: The percutaneous drainage tube was removed after one week, and the patient was discharged 6 months after admission. No adverse outcomes have been observed in the 2 years since the procedure. LESSONS: PCFs can be successfully managed using EUS-guided internalization with a balloon-target technique.

Early upsurge in anti-HBs titer possibly caused by the immunomodulative, not by the mutagenetic effect of interferon and ribavirin.

A patient with chronic hepatitis B and C undergoing treatment with interferon and ribavirin showed an upsurge in hepatitis B virus surface antibody (anti-HBs) titer, accompanied by a decrease in hepatitis B virus surface antigen (HBsAg) during the early treatment phase. Simultaneously, elevation of alanine aminotransferase (ALT) was observed. Subsequently, the hepatitis B virus (HBV) DNA titer decreased and HBV e antigen (HBeAg) to anti-HBe seroconversion occurred. The anti-HBs titer gradually returned to the pretreatment level after cessation of ribavirin treatment and HBV-DNA became undetectable. We found no nucleotide mutations in HBV-DNA that could explain the sudden elevation in anti-HBs titer. The appearance of anti-HBs was considered to be a break in immune tolerance against some epitopes in HBsAg, possibly the r epitope, stimulated by interferon/ribavirin treatment. The immunomodulatory effect of ribavirin might have caused this unexpected early immune response to HBsAg that preceded seroconversion to anti-HBe.