[A Case of a Gastrointestinal Stromal Tumor of the Stomach with Lymph Node Metastasis].

A 87-year-old female was pointed out wall thickness in the upper part of gastric body for examination of anemia. The mass had a contrast effect, some of it protruded outside the wall, and the surrounding lymph nodes were enlarged. Upper endoscopy showed irregular ulcerative lesion with submucosal volume from posterior wall to the greater curvature in the upper part of gastric body. Biopsy was performed, and GIST of stomach was diagnosed. Surgery was performed for the GIST of the stomach. During open surgery, invasion of pancreatic tail was observed, therefore proximal gastrectomy with D1 lymph node dissection and distal pancreatectomy were performed. Pathologically, the tumor measured 95×78×65 mm with mitotic figures(38/50 high-power fields). Immunohistochemical analysis revealed that tumor cells expressed positive results for c-kit, α-SMA and CD34, and negative results for S-100 and desmin on the basis of the histology and immunostaining profile, the tumor was diagnosed as a GIST. The patient was classed as high risk according to Fletcher's risk classification. Tumor invades pancreatic tail, and lymph node metastasis was observed. She was discharged on the postoperative day 27 and alive without tumor recurrence at 6 months after surgery, not undergoing adjuvant chemotherapy.

[A Case of Resection of Leiomyosarcoma Suspected to Originate from the Right Ovarian Vein].

We present a 58-year-old female patient who underwent resection of a leiomyosarcoma arising from the right ovarian vein. She was referred to our hospital because of lower abdominal pain that had been present for 1 month prior to the visit. Ultrasound examination revealed a well-defined, smooth, lobulated, highly vascular mass(57 mm)adjacent to the distal portion of the duodenum. Contrast-enhanced computed tomography revealed the contrast enhancement mass (60 mm)located surround the right ovarian vein. In abdominal magnetic resonance image examination, the mass exhibited isointense signal on T1-weighted images, high signal on T2-weighted images, and restricted diffusion on diffusion- weighted images. We suspected primary leiomyosarcoma of the ovarian vein and proceeded with surgical intervention. On intraoperative findings, the mass was in contact with the duodenum and the inferior vena cava but dissection was easily achieved. We excised the mass together with the right ovarian vein. Pathological findings showed the mass was composed of proliferating spindle-shaped cells arranged in bundles. Some areas showed polygonal nuclear atypia and abnormal mitotic figures. Additional immunostaining showed positive for α-SMA, caldesmon, calponin, and negative for desmin, CD34, CKA1/AE3, S100. Based on the intraoperative findings, we diagnosed it as leiomyosarcoma arising of the right ovarian vein.

Depression is associated with discoordination between heart rate variability and physical acceleration in older women.

Background and Aims: It is well known that depression is closely associated with the autonomic nervous system and physical acceleration (PA), which may cause functional time-deviance between these two parameters. Exploring this relationship is important in sustaining the mental and physical health of older adults in daily life. However, few studies have assessed the relationship between depression and the coordination of parasympathetic nervous activity (PSNA) and PA. The present study was designed to investigate whether the coordination between PSNA and PA is associated with the mental state of healthy volunteers in normal daily lives and the underlying mechanism. Methods: In total, 95 adult women were divided into non-older and older groups comprising 50 (aged 20-59 years) and 45 (aged 60-85 years) women, respectively. PSNA and PA data were simultaneously obtained every minute for 24 h during the free-moving day using the ActiveTracer accelerometer. Lag time was determined as the time difference between PSNA and PA, and it was introduced as a parameter of %lag0, which is the percent ratio of the lag = 0 min between PSNA and PA in 1 h. The General Health Questionnaire 28 (GHQ28) was used to evaluate the effects of psychological distress, including depression. Results: In the hour before sleep, %lag0 was significantly lower in older women (38.7 ± 6.4) who had higher GHQ28 values (subscale D = 0, n = 12) compared with that in older women (19.4 ± 10.5) with lower values (subscale D ≧ 1, n = 33) (p < 0.05). Conclusion: Impairments in coordination between PSNA and PA are significantly associated with depression in older women, particularly in the hour before sleep on free-moving days.

Carbamazepine-Induced Systemic Lupus Erythematosus in a Patient With Idiopathic Trigeminal Neuralgia: A Case Report.

A 50-year-old woman presented with a mandibular second molar and facial pain and was diagnosed with idiopathic trigeminal neuralgia. Carbamazepine (CBZ) was initiated at 300 mg/day, successfully relieving the pain. However, on the 8th day of CBZ treatment, the patient developed symptoms resembling those of systemic lupus erythematosus with malaise, nausea, and facial erythema. CBZ was immediately discontinued. Subsequently, she experienced numbness in both lower limbs and mild fever, which resolved within a few days. Laboratory tests revealed leukopenia (2.8 × 103/µL), elevated C-reactive protein levels (0.46 mg/dL), and the presence of antinuclear antibodies (ANA) and anti-Sjögren's syndrome-related antigen A antibodies. The clinical course suggested CBZ-induced drug-induced lupus erythematosus (DILE). This case highlights the possibility of DILE onset even after short-term CBZ treatment, the importance of prompt discontinuation of the causative drug in patients suspected of DILE, and the conduct of ANA testing in diagnosing DILE.

Associations between Periodontal Status and Liver Function in the Japanese Population: A Cross-Sectional Study.

A relationship between periodontitis and liver function has been suggested. Indeed, patients with severe periodontal disease have been found to be more prone to liver dysfunction. The periodontal inflammatory surface area (PISA) has been shown to be a useful indicator of periodontal and systemic diseases. However, little information is available regarding whether the PISA is associated with liver function markers, such as gamma-glutamyltransferase (GGT), aspartate aminotransferase (AST), and alanine aminotransferase (ALT). This study aimed to clarify relationship between liver function markers, AST, ALT, and GGT, and PISA level in a cross-sectional study. The subjects were recruited between 2018 and 2021 at the Medical and Dental Collaboration Center of Kanagawa Dental College Hospital. A periodontal clinical examination was performed, and the PISA was calculated. Peripheral blood samples were collected, and serum levels of liver function markers were measured. The levels of liver function markers were examined in different values of PISA. Participants with high PISA scores were more likely to have increased GGT levels while AST and ALT were not changed with PISA. Increased GGT was found in 10.8% and 29.4% (p = 0.0056), increased AST in 48.2% and 52.9% (p = 0.62), and increased ALT in 35.2% and 47.0% (p = 0.20) among <300 mm2 and ≧300 mm2 PISA groups, respectively. It was found that males with a PISA of 300 mm2 or higher had an elevated level of serum GGT. In conclusion, elevated GGT was found in the high PISA group, particularly in males, while AST and ALT did not differ by PISA.

Influence of Meal Sequence and Number of Teeth Present on Nutrient Intake Status: A Cross-Sectional Study.

Intake of fiber, as well as protein, and lipid preloading help to control postprandial glycemic elevation in people with type 2 diabetes and in healthy individuals. However, there are few studies on the awareness of meal sequence and nutrient intake status that consider oral conditions. This cross-sectional study aimed to determine the effects of meal sequences on nutrient intake status and whether these relationships were related to the number of teeth present. The subjects were recruited from the Medical and Dental Collaboration Center of Kanagawa Dental University Hospital between 2018 and 2021. Medical and dental examinations were performed, and a questionnaire was used to determine whether the diet consisted of vegetables, meat or fish, and carbohydrates in that order. Nutrient intake status was assessed using the brief-type self-administered diet history questionnaire. Data were collected from 238 participants. The group with awareness of meal sequence ingested increased nutrients such as n-3 fatty acids, total dietary fiber, calcium, and vitamin C. Saturated fatty acid intake increased in those with fewer teeth, while it was not significantly related to meal sequence. In conclusion, our results showed that meal sequence was associated with nutrient intake status. In addition, the intake of saturated fatty acids increased when many teeth were lost, regardless of meal sequence.

[A Case of Intussusception Caused by Ascending Colon Cancer That Underwent Elective Surgery without Repositioning].

An 81-year-old man visited his previous doctor with complaints of fever, vomiting, and diarrhea, and was transferred to our hospital on the 8th day after being admitted to the hospital for further treatment for a mass in the right side of his abdomen on CT. At the time of transfer, a fist-sized mass was palpable in the right side of the abdomen, but there was no tenderness, and blood tests showed that the white blood cell count was 10,700/µL and CRP 1.36 mg/dL, indicating a mild increase in inflammatory reaction. Contrast-enhanced CT showed an 8-cm diameter mass in the ascending colon with a stratified structure, and an antegrade intussusception with the mass as the advanced part. No intestinal obstruction was showed, and the contrast effect on the wall of the intestinal wall of the intussusception was favorable. Since the intussusception was already present on the previous CT scan, and since the patient also had severe aortic stenosis and a cardiothoracic examination was necessary, we decided on an elective operation. During the waiting period, lower gastrointestinal endoscopy revealed a type 1 tumor in the ascending colon, and biopsy revealed a highly differentiated tubular adenocarcinoma. The scope was not passed through to the oral side, and endoscopic repositioning was difficult. On the 19th day(12th day of admission), right hemicolectomy of the colon with D3 lymphadenectomy was performed. Since the descending duodenal wall was partially retracted into the area of the duplication, a partial resection of the duodenal wall was also performed, and the specimen was removed without releasing the duplication. Histopathologically, the tumor was diagnosed a 9.5×5.7 cm type 1 tumor with pT3, pN0, cM0, pStage Ⅱa(9th edition). The patient was discharged on the 9th postoperative day with good postoperative course.

[A Case of Ascending Colon Cancer with a Tumor Thrombus in the Superior Mesenteric Vein].

The progression of intravenous tumor thrombus in colorectal cancer is rare and reports on its resection are limited. This study reports a case of ascending colon cancer with a tumor thrombus in the superior mesenteric vein(SMV). A 44-year-old woman was admitted to our hospital for right, lower abdominal pain. Dynamic CT revealed an enhanced mass in the ascending colon and a tumor thrombus in the SMV. She was diagnosed with ascending colon cancer and an SMV tumor thrombus. An extended right hemicolectomy was performed. The SMV tumor thrombus extended from the gastrocolic trunk (GCT)to the right gastroepiploic vein and the anterior superior pancreaticoduodenal vein. To remove the tumor thrombus, a wedge-shaped incision was made through the SMV. Pathological examination showed a moderately differentiated adenocarcinoma of the ascending colon with extra-regional lymph node metastasis(No. 6)and intrapancreatic venous invasion. The pathological staging was pT4b, pN0, pM1a, pStage Ⅳa(Japanese Classification 9th edition). The patient was discharged on day 13 postoperatively. After discharge, 14 courses of mFOLFOX6 plus bevacizumab chemotherapy were administered. The patient is currently alive with no recurrence 15 months postoperatively.

Coordination between heart rate variability and physical activity may be diminished by fatigability in non-older women in the hour before sleep.

Fatigability is related to several diseases as well as the autonomic nervous system. We investigated whether fatigability is associated with coordination between physical acceleration (PA) and parasympathetic nervous activity (PSNA) in women. Overall, 95 women were divided into non-old (n = 50; age: 22-59 years) and old (n = 45; age: ≥60 years) groups. PSNA and PA data were simultaneously obtained every minute for 24 h. We defined %lag0 as the percent ratio of lag = 0 min between PSNA and PA in 1 h. Cornell Medical Index was used to determine the degrees of physical and psychological symptoms. In the non-older group in the hour before sleep, the participants with high fatigability scores had significantly lower %lag0 than those with low fatigability (p < 0.05). Additionally, those with higher fatigability combined with exhaustion in the morning had significantly lower %lag0 than those without exhaustion in the hour before sleep (p < 0.05) but not in the hour after waking up. These results suggest that fatigability in non-older women was associated with loss of coordination between PSNA and PA in the hour before sleep. Additionally, exhaustion in the morning may be related to loss coordination of PSNA and PA during the previous night.

Parasympathetic Nervous Activity Associated with Discoordination Between Physical Acceleration and Heart Rate Variability in Patients with Sleep Apnea.

Sleep apnea syndrome (SAS) often accompanies alterations in heart rate variability (HRV). The severity of SAS is sometimes evaluated using the oxygen desaturation index (ODI). We hypothesized that effects of the autonomic nervous system could be involved in the coordination between HRV and physical acceleration during free movement in patients with SAS. Among 33 women aged 60 years or older, 19 had a high ODI (>5). Their HRV and physical acceleration were simultaneously obtained every minute for 24 hours. The low frequency/high frequency (LF/HF) ratio and the high frequency in normalized units (HFnu) were used as HRV indices. Low levels of %Lag0, defined as the percentage of the lag = 0 min in 1 h, indicated coordination between physical acceleration and HRV. Nineteen participants were divided into group A (high %Lag0 before sleep [n = 9]) or group B (low %Lag0 [n = 10]). In group B participants with a high ODI and low %Lag0 in the hour after waking, HFnu was significantly increased compared to that in group A participants with high ODI and high %Lag0 in the hour after waking (p < 0.05). These results suggest that close associations between high ODI and discoordination between HRV and physical acceleration may be due to higher parasympathetic nervous system activity after waking.

Association of Periodontal Status, Number of Teeth, and Obesity: A Cross-Sectional Study in Japan.

Recent reports have shown an association between obesity and periodontitis, but the precise relationship between these conditions has yet to be clarified. The purpose of this study was to compare the status of periodontitis, tooth loss, and obesity. Participants comprised 235 patients at the Center for Medical and Dental Collaboration in Kanagawa Dental University Hospital between 2018 and 2020. Clinical examinations such as blood testing, body composition analysis, periodontal measurement, assessment of chewing ability, salivary testing, and oral malodor analysis were performed. Periodontal inflamed surface area (PISA) was significantly associated with the number of teeth and body mass index (BMI). The number of teeth was negatively associated with age, but positively with chewing ability. Chewing ability was associated negatively with age, and positively with high-sensitivity C-reactive protein (hsCRP). The level of methyl-mercaptan in breath and protein and leukocyte scores from salivary testing were positively associated with PISA. The rate of insufficient chewing ability was increased in subjects with hemoglobin (Hb)A1c ≥ 7%. The high PISA group showed increased hsCRP. BMI as an obesity marker was positively associated with PISA, indicating periodontal inflammation. Chewing ability was related to serum markers such as HbA1c and hsCRP.

[A Resected Case of Intussusception Due to Undifferentiated Carcinoma of the Colon].

An 89-year-old woman was pointed out to have anemia for a routine blood examination by her family doctor and was referred to our gastroenterological department for further examination. Colonoscopy showed a type Ⅰ tumor in the transverse colon and insertion of fiber across the tumor was difficult. On contrast enema using gastrographin, a crab's claw-like appearance was found. CT after contrast enema revealed a tumor, 5 cm in diameter with pseudokidney sign near the hepatic flexure of the transverse colon. Pathological examination of biopsy specimen proved the tumor to be a poorly differentiated adenocarcinoma. Thus, she was diagnosed with intussusception due to transverse colon cancer and we performed partial resection of the transverse colon without regional lymphadenectomy. Final pathological diagnosis of the tumor was undifferentiated carcinoma and tumor stage was pT3pN0cM0, pStage Ⅱa. She was discharged 13 days after surgery and alive without tumor recurrence at 7 months after surgery, not undergoing adjuvant chemotherapy.

[A Case of Conversion Surgery following Chemotherapy for HER2-Positive Advanced Gastric Cancer].

A 73-year-old female was referred to the gastroenterological department of our hospital for examination because of anemia. CA19-9 increased to 1,392 U/mL, and upper endoscopy revealed type 2 gastric cancer extending from the anterior wall to the lesser curvature in the lower part of the gastric body. Biopsy specimens revealed well-differentiated tubular adenocarcinoma, and HER2 was positive immunohistologically. Contrast-enhanced CT revealed wall thickness of the lower part of the gastric body with marked lymph node swelling beside the lesser curvature and a low-density nodule measuring 10 mm in diameter with rim enhancement in segment 5 of the liver, indicative of liver metastasis. Thus, she was diagnosed with unresectable advanced gastric cancer(cT3cN2M1, HEP, cStage ⅣB), and combined chemotherapy with capecitabine, cisplatin, and trastuzumab was administered. After 7 courses, CA19-9 normalized, and upper endoscopy revealed a scar of the primary tumor, and cancer was not detected in the biopsy specimen. On contrast-enhanced CT, lymph nodes beside the lesser curvature shrank significantly, and liver nodules disappeared. She was referred to our department for conversion surgery, and distal gastrectomy with D2 lymph node dissection was performed 7 months after her first visit to our hospital. Pathologically, tumor invasion was restricted to the lamina propria, and lymph node metastasis was not observed(ypT1aN0M0, ypStage Ⅰ A). She was discharged on postoperative day 13 and is alive without tumor recurrence at 7 months after surgery. She is not currently undergoing adjuvant chemotherapy.

How to Increase Number of Present Teeth in Elderly: Consideration of Percentile Curves for Present Teeth in Tokyo.

Maintaining dental and oral health and increasing healthy life expectancy are important issues for Japan as it deals with the rapid aging of its population. The purpose of this study was to determine effective dental health measures aimed at increasing the number of present teeth in the elderly. Change in the number of present teeth was determined based on data obtained from the 2009 and 2014 "Good Teeth Tokyo (Ii-ha Tokyo)" surveys carried out by the Tokyo Metropolitan Government. The number of present teeth and percentile curves were compared between these two time points. The number only showed a significant increase in individuals aged 60 years in 2014 (p<0.05). This may have been due to the establishment of a national public insurance system. The number of present teeth showed an increase in 2014 in the 25th, 50th, and 75th percentile curves. In the 75th and 90th percentile curves, tooth loss accelerated when the number of present teeth was fewer than 25. This finding is consistent with studies reporting that tooth loss itself is a risk for tooth loss. Tooth loss showed a slight acceleration between the ages of approximately 20 and 45 years in the 90th percentile curve. These results indicate that dental check-ups at universities and companies, periodontal disease check-ups performed by local governments, and health instruction at these check-ups are necessary to increase the number of present teeth in the elderly. They further suggest that implementing measures to promote periodic visits to dental clinics and providing incentives to undergo treatment for tooth defects are necessary in high-risk individuals. In conclusion, dental check-ups, health instruction, and strategies for high-risk individuals in their 20s and 40s are necessary to increase the number of present teeth in the elderly.

Needle tract seeding following endoscopic ultrasound-guided fine-needle aspiration for pancreatic cancer: a report of two cases.

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a useful tool in pancreatic cancer diagnosis. However, the procedure itself may cause peritoneal dissemination and needle tract seeding at the puncture site. We herein report two cases of gastric wall metastasis due to needle tract seeding after EUS-FNA. CASE PRESENTATION: Case 1: A 68-year-old woman was admitted to our hospital for persistent cough. Computed tomography (CT) scan revealed inflammatory changes in the left lung field, and incidentally, a 15-mm hypovascular mass was detected in the pancreatic body. She underwent EUS-FNA and was diagnosed as pancreatic adenocarcinoma. She underwent distal pancreatectomy with splenectomy; however, a small hard mass was observed in the posterior gastric wall during surgery. We performed partial gastrectomy, and the resected specimen was diagnosed as a needle tract seeding following EUS-FNA. She then underwent adjuvant chemotherapy with TS-1, but the pancreatic cancer showed recurrence 6 months after surgery. She died due to peritoneal dissemination 18 months after surgery. Case 2: A 70-year-old man was incidentally detected with a pancreatic body mass on a CT scan as part of his follow-up for recurrence of basal cell carcinoma. He underwent EUS-FNA and was diagnosed as pancreatic adenocarcinoma. He had nodules in both lungs, and it was difficult to differentiate them from lung metastasis of pancreatic cancer. Therefore, he underwent neoadjuvant chemoradiotherapy, and thereafter, the lung nodules showed no changes; hence, he underwent distal pancreatectomy with splenectomy. During surgery, we observed a hard mass in the posterior gastric wall. We performed partial gastrectomy, and the resected specimen was diagnosed as needle tract seeding due to EUS-FNA. He underwent chemotherapy with TS-1, and he is still alive 18 months after surgery at the time of writing. CONCLUSION: For resectable pancreatic body or tail tumors, EUS-FNA should be carefully performed to prevent needle tract seeding and intraoperative as well as postoperative assessment for gastric wall metastasis is mandatory.

Systemic hemodynamics in advanced cirrhosis: Concerns during perioperative period of liver transplantation.

Advanced liver cirrhosis is usually accompanied by portal hypertension. Long-term portal hypertension results in various vascular alterations. The systemic hemodynamic state in patients with cirrhosis is termed a hyperdynamic state. This peculiar hemodynamic state is characterized by an expanded blood volume, high cardiac output, and low total peripheral resistance. Vascular alterations do not disappear even long after liver transplantation (LT), and recipients with cirrhosis exhibit a persistent systemic hyperdynamic state even after LT. Stability of optimal systemic hemodynamics is indispensable for adequate portal venous flow (PVF) and successful LT, and reliable parameters for optimal systemic hemodynamics and adequate PVF are required. Even a subtle disorder in systemic hemodynamics is precisely indicated by the balance between cardiac output and blood volume. The indocyanine green (ICG) kinetics reflect the patient's functional hepatocytes and effective PVF, and PVF is a major determinant of the ICG elimination constant (kICG) in the well-preserved allograft. The kICG value is useful to set the optimal PVF during living-donor LT and to evaluate adequate PVF after LT. Perioperative management has a large influence on the postoperative course and outcome; therefore, key points and unexpected pitfalls for intensive management are herein summarized. Transplant physicians should fully understand the peculiar systemic hemodynamic behavior in LT recipients with cirrhosis and recognize the critical importance of PVF after LT.

How do transplant surgeons accomplish optimal portal venous flow during living-donor liver transplantation? Noninvasive measurement of indocyanine green elimination rate.

BACKGROUND: Balancing donor safety and graft volume is difficult. We previously reported that intentional modulation of portal venous pressure (PVP) during living-donor liver transplantation (LDLT) is crucial to overcoming problems with small-for-size grafts; however, detailed studies of portal venous flow (PVF) and a reliable parameter are still required. PATIENTS AND METHODS: The elimination rate (k) of indocyanine green (ICG) was measured in 49 adult LDLT recipients. PVP was controlled during LDLT, with a target of <20 mm Hg. ICG reflects hepatocyte volume and effective PVF. The kICG value is divided by the graft weight to calculate PVF. Recipients were divided into 2 groups: those with severe and/or fatal complications within 1 month after LDLT and those without. RESULTS: Survival rates and postoperative profiles were significantly different between the 2 groups. Univariate analysis showed significant differences in ABO blood group, final PVP, final kICG, and the final kICG/graft weight value; however, multivariate analysis showed that only the kICG/graft weight value was significant. The cutoff level for the final kICG/graft weight value for predicting successful LDLT was 3.1175 × 10(-4)/g. CONCLUSION: Accurate evaluation and monitoring of optimal PVF during LDLT should overcome the use of small-for-size grafts and improve donor safety and recipient outcomes.

Malignant pheochromocytoma: Hepatectomy for liver metastases.

Malignant pheochromocytoma accounts for approximately 10% of pheochromocytoma cases. The main site of distant metastasis is the liver. Hypertensive crisis due to catecholamine oversecretion is potentially fatal. We present a case of malignant pheochromocytoma with multiple liver metastases. A 60-year-old female with repeated hypertensive episodes was diagnosed with malignant pheochromocytoma. She underwent a left adrenalectomy and partial hepatectomy with resection of segment 6. Catecholamine levels remained high after surgery and she received repeated cycles of chemotherapy. Four months after surgery, multiple liver metastases were detected. In spite of ongoing chemotherapy, catecholamine levels eventually became uncontrollable. Serum and urine noradrenaline and vanillylmandelic acid levels increased, but adrenaline and dopamine levels stayed within the normal range. Preoperative liver imaging revealed multiple metastases in all segments except segment 4. Percutaneous transhepatic portal vein embolization (PTPE) of the right and lateral branches of the portal vein was performed. The functional liver volume of segment 4 increased after PTPE. Right hepatectomy, lateral segmentectomy and partial resection of segment 1 were performed 10 mo after the initial surgery. Intraoperative ultrasonography detected two small tumors in segment 4, which were treated with intraoperative microwave coagulation therapy. Noradrenaline levels normalized immediately after the second hepatectomy. As there was increased telomerase activity in the resected specimen, she received adjuvant chemotherapy. She remained in good health for 2 years. However, further metastases eventually occurred and she subsequently died due to a brain hemorrhage. Hepatectomy may be a therapeutic option for reduction of tumor mass in pheochromocytoma with liver metastases.