Development of acute hydrops in eye with infectious keratitis: A case report.

Purpose: To determine the characteristics of an eye that developed acute hydrops while being treated for infectious keratitis. Observation: A 35-year-old man presented with pain and blurred vision in his left eye. He had undergone cataract surgery seven years earlier and was being treated for poorly controlled atopic dermatitis. The decimal best-corrected visual acuity (BCVA) of the left eye was 0.01. Slit-lamp microscopy showed conjunctival injection, corneal opacification, and a corneal ulcer. The patient was diagnosed with infectious keratitis and was treated with topical and systemic antibiotics. During the hospitalization, the patient was noted to rub his eyes frequently and vigorously. Five days after the first visit, the cornea protruded markedly, and the stroma surrounding the ulcerated area was edematous. These findings led to a diagnosis of acute hydrops.Penetrating keratoplasty was performed to prevent corneal perforation. Histopathological study of the excised cornea showed stromal edema, infiltration of leukocytes, and a tear in Descemet's membrane. Unfortunately, the patient developed endophthalmitis the day after the surgery. The anterior chamber was irrigated with antibiotics, and antibiotics were also injected into the vitreous. The endophthalmitis gradually subsided, and two years after the surgery, the patient's decimal BCVA had improved to 0.6. Conclusion and importance: Vigorous eye rubbing in cases of infectious keratitis can induce acute hydrops, and timely surgical intervention is recommended.

[A Case of COVID-19 Infection during Postoperative Chemotherapy for Breast Cancer Treated with Antibody Cocktail Therapy to Prevent Disease Aggravation].

The outbreak of COVID-19 has caused a global pandemic, and it has been reported that patients with cancer are at high risk of developing complications from the disease. However, we believe that prolonged interruption of chemotherapy due to extended COVID-19 treatment is not desirable, given the intensity of cancer treatment. We report a case of COVID-19 infection during postoperative chemotherapy for breast cancer, in which antibody cocktail therapy prevented disease aggravation and delayed breast cancer treatment. The patient is a 45-year-old woman who came to our hospital with a complaint of a right mammary mass. The mass was diagnosed as invasive ductal carcinoma with an ER and PR of 0%, a HER2 score of 1+, and a Ki-67 of 90%. After preoperative chemotherapy, she underwent a right mastectomy and axillary dissection. The pathology result showed non-pCR. The administration of capecitabine was started as adjuvant therapy. On day 8 of cycle 3, she developed a fever in the 39℃ range, and on the next day, a COVID-19 POC gene test confirmed that the patient was positive for infection. On the same day, neutralizing antibody drugs(casirivimab and imdevimab)were administered as antibody cocktail therapy. Two days after treatment(day 11), a blood test showed Grade 3 neutropenia, but there was no recurrence of fever or evidence of pneumonia. After 2 weeks, capecitabine was resumed, and the patient was able to complete 8 cycles of capecitabine therapy without any major complications.

[ESR1 Mutation-Positive Recurrent Breast Cancer Successfully Treated with Letrozole plus Abemaciclib].

Approximately 70% of breast cancers are estrogen receptor(ER)positive, an indication for endocrine therapy. The first choice of treatment for ER-positive metastatic recurrent breast cancer is endocrine therapy, which has relatively few side effects; however, many of these side effects become resistant during treatment. One of the resistance mechanisms is mutations in the ESR1 gene, which have also been found to occur after long-term aromatase inhibitor(AI)treatment. Here, we describe our experience of a case in which long-term PR was achieved with AI(letrozole)plus abemaciclib despite ESR1 mutation positivity in cancer genetic screening and review the literature.

[A Case Study of Successful Breast Cancer Treatment after Recovery from Drug-Induced Interstitial Lung Disease].

Drug-induced interstitial lung disease(DILD)is a possible complication of many anticancer drugs. When DILD occurs during breast cancer treatment, choosing the right drug for subsequent treatment is often difficult. In our first case, the patient developed DILD during dose-dense AC(ddAC)therapy; however, the disease resolved with steroid pulse therapy, and the patient underwent surgery without disease progression. In the second case, a patient on anti-HER2 therapy for recurrent disease developed DILD in response to docetaxel plus trastuzumab plus pertuzumab administered to treat T-DM1 after progressive disease. In this report, we describe a case of DILD that did not worsen and the patient had successful treatment outcome.

[Olaparib Could Be Re-Administered after Chemotherapy].

Olaparib, a PARP inhibitor, was approved in 2018 for BRCA1/2 gene mutation and HER2-negative inoperable or recurrent breast cancer with previous chemotherapy. Olaparib is an important drug with minor adverse events compared to chemotherapeutic drugs. In addition, it is expected to exert a high therapeutic effect on breast cancer with BRCA mutations due to its characteristics. We report a case of BRCA2-mutated breast cancer in a patient in whom olaparib was initiated. The patient complained of strong nausea; however, the treatment could be continued by reducing the dose of olaparib to 400 mg and using multiple drugs such as antiemetics and anxiolytics in advance.

[A Case of Severe Drug-Induced Lung Injury during Preoperative Chemotherapy for Breast Cancer in the Early Stages of the COVID-19 Epidemic].

Drug-induced interstitial lung disease(DILD)is defined as a drug-related respiratory disorder that occurs during drug administration. For diagnosis, it is important to differentiate similar diseases. We report a case of severe drug-induced lung injury during preoperative chemotherapy for breast cancer in the early stages of the COVID-19 epidemic, which was difficult to diagnose. The patient was a 48-year-old woman. The chief complaint was fever and dyspnea. She was diagnosed with left breast cancer(ER 30-40%, PR 0%, HER2 1+, Ki-67 84%), cT4bN1M0, cStage ⅢB and was treated with dose-dense AC therapy and docetaxel sequentially as preoperative chemotherapy. On the 21st day of the first course of docetaxel, the patient developed respiratory failure. A CT scan of the chest showed diffuse ground-glass shadows in the bilateral lung fields, suggesting severe viral pneumonia caused by COVID-19, and the patient was admitted to the isolation ward and managed with an intubated ventilator. PCR and LAMP were negative, and COVID-19 was ruled out. Based on the clinical course and CT findings, we started steroid pulse therapy with DILD in mind. The patient was extubated on the 5th day after the onset of the disease because the steroid pulse therapy was successful and her respiratory condition was stable. Preoperative chemotherapy was stopped, and a left mastectomy and axillary dissection were performed. In this case, COVID-19 should have been suspected first, but we were able to minimize the interruption of treatment by taking early action and keeping DILD in mind.

Case of unilateral pellucid marginal corneal degeneration progressing to corneal perforation with keratoconus in contralateral eye.

PURPOSE: To report our findings in a case of pellucid marginal corneal degeneration (PMCD) in the left eye and keratoconus (KC) in the right eye, and to review earlier cases of PMCD and KC. OBSERVATIONS: A 45-year-old woman visited our hospital with a complaint of reduced vision in her right eye. She was predisposed to allergies since childhood and had a habit of rubbing her eyes. Based on the results of the corneal topographic study, we diagnosed her with KC in the right eye and PMCD in the left eye. We prescribed a rigid, gas permeable contact lens and treated her allergic conjunctivitis with ocular medications. Three years after her initial visit, she developed a corneal perforation in the left eye. The perforation was closed by conservative treatment consisting of therapeutic soft contact lens wear. One year after the cornea healed, the corneal astigmatism in the left eye was about one-half of what it was before the corneal perforation. Her corrected visual acuity improved to 1.0 with conventional spectacles. CONCLUSIONAND IMPORTANCE: We found a difference in the progression of KC and PMCD even when they occurred in same individual. We suggest that the atopic predisposition, which is considered a risk factor for acute hydrops in KC, to be a risk factor for acute hydrops and corneal perforation in eyes with PMCD.

Successful multi-stage treatment of stoma limb perforation following Hartmann's operation report a case.

BACKGROUND: Stoma-related complications are not rare, whereas the spontaneous perforation of the stoma limb is relatively rare. Herein, we report a case of stoma limb perforation which occurred after Hartmann's operation. CASE PRESENTATION: A 50-year-old Japanese man presented to our Hospital with acute and severe abdominal pain. Abdominal computed tomography (CT) scan revealed that an abscess with free air was formed around the sigmoid colon. We performed Hartmann's operation, whereas he experienced redness, purulent discharge, and swelling around the colostomy at 10 days postoperatively. The contrast-enhanced CT scan of the abdomen revealed an abscess formation with air around the colostomy. He was diagnosed with an abdominal wall abscess due to perforation of the stoma limb. After the drainage, his symptoms were ameliorated by oral analgesics, anti-inflammatory drugs, and prophylactic antibiotic. Four months after the first operation, we performed a closedown of the sigmoid colostomy and fistula resection. The patient's postoperative course was uneventful, and he was discharged 14 days later. CONCLUSIONS: This case depicts rare complications of Hartmann's operation. Operation is usually performed in patients with stoma limb perforation. However, if they are stable and the abscess is located in their abdominal wall, they may be treated successfully using a multi-stage approach of local drainage toward the stoma wall followed by stoma closure.

Laparoscopic omentectomy in primary torsion of the greater omentum: report of a case.

BACKGROUND: Torsion of the greater omentum is a rare cause of acute abdominal pain in adults and children. It is very difficult to make a correct diagnosis of torsion clinically because it mimics other acute pathologies; however, the preoperative diagnosis can be easily confirmed with the use of computed tomography (CT). Herein, we report a case of laparoscopic omentectomy for primary torsion of the omentum, which was not improved by conservative treatment. CASE PRESENTATION: A 50-year-old Japanese man presented to our hospital with acute right lower quadrant abdominal pain of a few hours' duration. Routine blood tests showed a white blood cell count of 8900/mm3, and the C-reactive protein (CRP) level was 8.13 mg/dl. Contrast-enhanced CT scan of the abdomen revealed twisting of the omentum with a local mass of fat density and fluid distributed in a whirling oval-shaped mass pattern at the right flank and iliac fossa. Therefore, the patient was admitted to our hospital based on a diagnosis of omental torsion. The patient was treated with conservative treatment with analgesics, anti-inflammatories, and antibiotics. Although his symptoms were ameliorated, his laboratory and radiological findings worsened. We performed laparoscopic omentectomy 6 days after admission. The resected omentum was 24 cm × 22 cm in size and was twisted and dark red in color, suggesting infarction. Histological analysis revealed that the specimen was ischemic and hemorrhagic omentum, accompanied by inflammatory infiltration. The patient's postoperative course was uneventful, and he was discharged 9 days later. CONCLUSION: This is a rare case of primary torsion of the greater omentum that was treated successfully with laparoscopic omentectomy. Considering the increase in surgical difficulty due to inflammation from prolonged torsion and the limited efficacy of conservative treatment, we conclude that surgical intervention is warranted as early as possible when torsion of the greater omentum is suspected.

Laparoscopic Total Devascularization of the Upper Stomach and Splenectomy (Hassab's Procedure) Under Indocyanine Green Fluorescence Imaging: Initial Experience.

The use of surgical treatment for refractory isolated gastric varices has decreased owing to the development of endoscopic and radiologic procedures, although surgeries are sometimes required as the final method. A 75-year-old Japanese woman was diagnosed with solitary gastric varices. Initially, intraoperative splenic artery embolization was performed using the balloon transcatheter technique under general anesthesia. Laparoscopic splenectomy was performed safely owing to preoperative splenic artery embolization. Intraoperative indocyanine green (ICG) fluorescence angiography was performed following the injection of 5 mL of ICG; the remnant stomach was observed using laparoscopic equipment with an ICG imaging system, and blood flow from the remnant gastric artery was confirmed. The blood did not pool or wash out immediately, which confirmed successful devascularization of the stomach. The total operative time was 269 minutes, and the intraoperative blood loss was 500 mL. The patient's postoperative course was good, and at 21 days after the last operation, she was discharged from our hospital in remission. Real-time fluorescence angiography with ICG is a reliable and objective technique of assessing blood flow of the stomach. Accurate, extensive devascularization in the lower esophagus and upper stomach was performed using Hassab's procedure in combination with ICG imaging.

Surgical strategy for suspected early gallbladder carcinoma including incidental gallbladder carcinoma diagnosed during or after cholecystectomy.

PURPOSE: This paper presents an overview of the surgical strategy for patients with suspected gallbladder carcinoma (GBC), including incidental GBC cases, preoperatively or intraoperatively, as well as their outcomes. METHODS: Between April 2009 and December 2017, 529 patients underwent cholecystectomy for gallbladder disease at our hospital. Both intraoperative and postoperative histological examinations of the excised gallbladder facilitated the diagnosis of GBC. Surgery-related variables and surgical approaches were evaluated according to the extent of tumor invasion. RESULTS: Of 529 patients, eight were diagnosed with GBC during/after cholecystectomy, including four women and four men. Mean age was 75.4 (range, 59-89) years. Five patients had gallbladder stones and three had cholecystitis. Three patients with stages T1b and T2 underwent additional liver bed wedge resections with or without prophylactic common bile duct excision. Five of the eight patients are still alive and two of the remaining three died from other diseases; one patient with pT3 died of recurrent GBC (peritonitis carcinomatosa). CONCLUSION: Because of the ability to obtain full-thickness frozen biopsies during laparoscopic cholecystectomy, we could diagnose GBC intraoperatively, allowing for rapid diagnosis and tumor resection. We recommend developing a surgical treatment strategy for suspected early GBC in advance of cholecystectomy.

Laparoscopic Excisional Cholecystectomy with Full-Thickness Frozen Biopsy in Suspected Gallbladder Carcinoma.

Owing to the advantages of a laparoscopic approach, laparoscopic cholecystectomy (LC) is thought to be the treatment of choice in gallbladder disease, even in cases of suspected malignancy. However, it is difficult to differentiate between cholecystitis and gallbladder carcinoma (GBC). We performed radical hepatectomy in patients with pT2 GBC diagnosed by full-thickness frozen biopsy. A 75-year-old Japanese man presented to our hospital with discomfort in the right upper quadrant of the abdomen. This patient was diagnosed with suspected GBC and was scheduled to undergo LC and intraoperative histological examination. Following the procedure, we made a diagnosis of GBC with negative invasion of the cystic duct stump. We converted the laparoscopic procedure to an open surgery involving wedge liver resection with lymphadenectomy. The patient was discharged from our hospital in remission 14 days following the radical hepatectomy. Histological examination showed that the GBC had invaded the liver (T3a), but there was no lymph node metastasis (N0): stage IIIA. Between April 2009 and September 2018, 580 patients underwent cholecystectomy for gallbladder disease at our hospital. Among these, 8 (1.4%) were suspected to have GBC preoperatively and underwent laparoscopic excisional cholecystectomy. We performed elective surgery in the early stage in two patients and second-look surgery in two patients recently. We were able to perform what we termed a laparoscopic excisional cholecystectomy, involving LC with a full-thickness frozen biopsy, even in situations where intraoperative histological examination was not available. Altogether, laparoscopic excisional cholecystectomy is an effective surgical treatment for suspected early GBC.

Conjunctival Goblet Cell Density Following Cataract Surgery With Diclofenac Versus Diclofenac and Rebamipide: A Randomized Trial.

PURPOSE: To determine the effects of topical diclofenac or betamethasone with concomitant application of topical rebamipide on the conjunctival goblet cell density in eyes after cataract surgery. DESIGN: Randomized clinical trial. PARTICIPANTS: Eighty patients who were scheduled for cataract surgery. METHODS: Patients were randomized into 4 groups according to the postoperative topical drugs to be given; Group A, diclofenac alone; Group B, diclofenac and rebamipide; Group C, betamethasone alone; and Group D, betamethasone and rebamipide. Impression cytology was performed before and at 1 month after the surgery, and the mean density of goblet cells was determined. RESULTS: The mean (± SD) density of goblet cells before the surgery in Group A was 257.0 ± 188.7 cells/mm2, and it decreased significantly to 86.5 ± 76.7 cells/mm2 at 1 month after the surgery (P = .002). In Group B, the goblet cell density was not statistically different between before (238.5 ± 116.6 cells/mm2) and at 1 month after the surgery (211.3 ± 184.4 cells/mm2, P = .55). In Groups C and D, the mean density of goblet cells was decreased at 1 month after the surgery, but the decreases were not significant (P = .11 and P = .52, respectively). CONCLUSION: After cataract surgery with postoperative topical diclofenac, the conjunctival goblet cell density was significantly reduced, and this reduction was blocked by the concomitant use of topical rebamipide. These results suggest that the concomitant use of topical rebamipide with nonsteroidal anti-inflammatory drugs is beneficial, especially in cases with postoperative dry eyes.

Method of Quantifying Size of Retinal Hemorrhages in Eyes with Branch Retinal Vein Occlusion Using 14-Square Grid: Interrater and Intrarater Reliability.

Purpose. To describe a method of quantifying the size of the retinal hemorrhages in branch retinal vein occlusion (BRVO) and to determine the interrater and intrarater reliabilities of these measurements. Methods. Thirty-five fundus photographs from 35 consecutive eyes with BRVO were studied. The fundus images were analyzed with Power-Point® software, and a grid of 14 squares was laid over the fundus image. Raters were asked to judge the percentage of each of the 14 squares that was covered by the hemorrhages, and the average of the 14 squares was taken to be the relative size of the retinal hemorrhage. Results. Interrater reliability between three raters was higher when a grid with 14 squares was used (intraclass correlation coefficient (ICC), 0.96) than that when a box with no grid was used (ICC, 0.78). Intrarater reliability, which was calculated by the retinal hemorrhage area measured on two different days, was also higher (ICC, 0.97) than that with no grid (ICC, 0.86). Interrater reliability for five fundus pictures with poor image quality was also good when a grid with 14 squares was used (ICC, 0.88). Conclusions. Although our method is subjective, excellent interrater and intrarater reliabilities indicate that this method can be adapted for clinical use.

Effect of topical rebamipide on conjunctival goblet cell recovery after vitrectomy.

In vitro and in vivo experiments have shown that topical rebamipide will increase the number of goblet cells in the bulbar conjunctiva. The purpose of this study was to determine whether topical rebamipide will enhance the recovery of conjunctival goblet cells that were damaged during vitrectomy. Forty patients who underwent vitrectomy surgery were studied. The 40 patients consisted of 20 with diabetes mellitus (DM) and 20 patients without DM. They were randomized in a 1:1 ratio into groups that were treated or not treated with topical 2% rebamipide after the surgery. Impression cytology was performed at the end of surgery and at 14 days after the surgery. The mean goblet cell density of each specimen was determined by averaging the total number of goblet cells obtained from three consecutive high magnification microscopic images. In patients without DM, the mean goblet cell density at 14 days after the vitrectomy was significantly higher in eyes with topical rebemipide than in eyes without rebemipide (P < 0.01). In patients with DM, a similar tendency was observed but the difference was not significant (P = 0.09). These results suggest that topical rebamipide can be helpful in patients with globlet cell damage that occur during and after vitrectomy.

Histopathologic findings of perforated corneas due to ferric ion infiltration.

OBJECTIVE: To report the histopathologic findings of 3 corneal buttons incised from 2 patients during penetrating keratoplasty (PKP) because of corneal perforation due to corneal siderosis. METHODS: Three eyes of 2 patients had accidental trauma to the corneas caused by iron fragments; the injuries were initially treated conservatively with antibiotics and therapeutic soft contact lenses. However, the corneal stroma melted and perforated, necessitating corneal transplantation. The corneal buttons removed during PKP were examined histopathologically, and the findings were compared with the slit-lamp biomicroscopic and anterior segment optical coherence tomographic (AS-OCT) findings. RESULTS: Slit-lamp examinations showed that the corneal epithelium was hyperplasic around the area of perforation in 2 eyes 1 month after the injury. Wide areas of the stroma had melted, and the corneas were perforated. The corneal epithelium was atrophic in the perforated corneas 4 months after injury. Histopathologically, the corneal stroma and Descemet's membrane were stained by Prussian blue, suggesting that the ferric ions had penetrated deeper than expected by the slit-lamp examinations. The areas of Prussian blue staining corresponded well with the areas altered in the AS-OCT images. CONCLUSIONS: Ferric ions penetrate much deeper into the cornea than estimated by slit-lamp biomicroscopy. The ferric ions can induce stromal melting that can lead to corneal perforation. We conclude that (i) the ferric ion-infiltrated areas can be estimated in the AS-OCT images and (ii) extensive corneal abrasion should be performed to prevent corneal melting and perforation.

Predictors of maternal state anxiety on arrival at a Japanese hospital outpatient clinic: a cross-sectional study.

AIMS AND OBJECTIVES: To identify the factors that predict maternal state anxiety when mothers and their sick children visit the outpatient unit of a paediatric hospital. BACKGROUND: While previous studies have focused on predictors of anxiety in mothers with ill children, the existing literature is limited in study design, research timing, respondent characteristics, sample size and data analysis. DESIGN: A cross-sectional design with self-administered questionnaires. METHODS: Mothers were recruited from the outpatient unit of a Japanese paediatric hospital (N = 1077). Participants' state anxiety scores were collected using the Japanese version of Spielberger's State-Trait Anxiety Inventory. The independent variables were the mothers' and sick children's background information. RESULTS: Participants were 1077 mothers; 990 provided valid responses. Mothers' mean state anxiety score was 49·72. Significant predictors of maternal anxiety were mothers' childrearing anxiety, child age, the sick child having a fever, sick child having siblings, having a person providing childrearing support, the mother's first visit to the hospital, out-of-hours visit and severity of the child's illness. The overall model explained 21·6% of the variance (multiple regression analysis). CONCLUSIONS: As various factors predicted maternal anxiety, identifying methods to address these factors may reduce maternal state anxiety. RELEVANCE TO CLINICAL PRACTICE: There is potential for improved understanding of the predictors of maternal state anxiety to aid in the development of materials that would best measure anxiety. The present findings may also suggest some means of providing appropriate information and support to anxious mothers. Our findings cannot demonstrate causation, however, and teaching methods and supportive practices were not investigated; therefore, a qualitative study on the concrete content of maternal anxiety and an intervention study to create support services for anxious mothers is required. In addition, prospective or longitudinal studies are also important for investigating causation.

Effectiveness of aromatherapy in decreasing maternal anxiety for a sick child undergoing infusion in a paediatric clinic.

OBJECTIVES: We examined whether aromatherapy involving inhalation of yuzu (Citrus ichangensis×Citrus reticulata) oil was effective in decreasing mothers' anxiety for her sick child receiving an infusion at a paediatric clinic. DESIGN: Controlled clinical trial. SETTING: Mothers of sick children who arrived at the hospital were asked to complete an anonymous questionnaire. After a doctor examined the child and confirmed the necessity for infusion, the mothers who agreed to participate in our study were allocated to an aromatherapy or a control group. INTERVENTIONS: A diffuser was filled with yuzu oil before the subjects entered the aromatherapy room. The mother was shown how to use the aromatherapy diffuser while the child was receiving an infusion in the same room. Fifteen minutes after entering the room, the mothers were asked to complete an another questionnaire. MAIN OUTCOME MEASURES: We measured the mother's anxiety with the state anxiety score from the State-Trait Anxiety Inventory. RESULTS: There were 60 subjects in the aromatherapy group and 61 in the control group. Both groups were well balanced in terms of demographic characteristics. Using analysis of variance, we demonstrated a significant difference in two-factor interactions between the control and aromatherapy groups. Maternal state anxiety was significantly lower in the aromatherapy than in the control group. CONCLUSIONS: Inhalation of yuzu oil was shown to decrease maternal anxiety for a sick child. A multicentre randomized controlled trial or double-blind study is necessary to obtain objective evidence of this benefit of aromatherapy.

Probing of congenital nasolacrimal duct obstruction with dacryoendoscope.

BACKGROUND: A congenital nasolacrimal duct obstruction (CNLDO) is a relatively common disease in infants. We evaluated the results of probing three patients with CNLDO, under direct view, with a dacryoendoscope. METHODS: Three cases of CNLDO were examined and treated by probing with a dacryoendoscope, under intravenous anesthesia. The diameter of the dacryoendoscope probe was 0.7 mm, and we were able to observe the inner walls of the lacrimal duct and able to guide the probe through the duct. RESULTS: In all cases, the site of obstruction was detected, and the probe was used to remove the obstruction. At 2 weeks after the removal of the obstruction, there was no epiphora or mucopurulent discharge in any of the cases. No complications were detected intra- and postoperatively. CONCLUSION: Although only three cases were studied, we believe that probing with a dacryoendoscope is a safe and effective method of treating a CNLDO. More cases need to be studied.