Post-embolization syndrome-like symptoms due to shedding of necrotic material of hepatocellular carcinoma into the bile duct following transcatheter arterial chemoembolization: an instructive case.

Fever, abdominal pain, and liver dysfunction are almost inevitable complications of transcatheter arterial chemo embolization (TACE) for hepatocellular carcinoma, but these symptoms may also be due to bile duct obstruction caused by shedding of necrotic tumor material into the bile duct. A 68-year-old man presented with persistent fever, liver dysfunction, and abdominal pain after TACE. Computed tomography revealed stone-like hyperdensities in the bile duct. Endoscopic retrograde cholangiopancreatography revealed these structures to be necrotic material from hepatocellular carcinoma. We believe this is an instructive case of an often overlooked situation.

Two tumor types in a unilateral testis in a patient with severe oligozoospermia and a history of cryptorchidism surgery: A case report.

Testicular cancer, the most common cancer among young male adults, is associated with infertility. A 38-year-old male patient was admitted to Dokkyo Medical University Saitama Medical Center, Japan, with infertility associated with severe oligozoospermia. Scrotal ultrasonography revealed two distinct tumors in the left testis: A mass with abundant blood flow on the cranial side and a mass with poor blood flow on the caudal side. Additional analysis revealed mild elevation of intact human chorionic gonadotropin (hCG) levels (tumor marker level assessment), high testosterone and low luteinizing hormone and follicle-stimulating hormone levels (hormonal level assessment) and severe oligoasthenozoospermia (semen assessment). The preoperative diagnosis was left-sided testicular cancer and severe oligoasthenozoospermia and the patient underwent left high orchiectomy and oncological testicular sperm extraction. Based on the pathological assessment, the cranial tumor was diagnosed as a seminoma with syncytiotrophoblastic cells, whereas the caudal tumor had only scar tissue with germ cell neoplasia in situ in the adjacent parenchyma. Following surgery, intact hCG and hormone levels of the patient were normalized, and the semen parameters (semen volume, sperm density, and motility) improved dramatically. To the best of our knowledge, the present case is the first report of two types of testicular tumor in a unilateral testis in a patient with a history of cryptorchidism surgery. The present case demonstrated that scrotal ultrasonography should be performed in patients with abnormal semen results to rule out testicular tumors.

Rotating suture technique combined with lid margin split and lower eyelid retractor disinsertion for epiblepharon.

Epiblepharon is an eyelid disease affecting 46-52.5% of Asian children. The Hotz procedure was commonly used for the treatment. However, the currently preferred technique is the rotating suture technique. This study aimed to report the recurrence rate and the complications of using the rotating suture technique combined with lid margin split and lower eyelid retractor (LER) disinsertion of epiblepharon. This was a retrospective study of the procedures performed between January 2017 and December 2020. This study included 64 eyelids of 37 patients who underwent the consecutive rotating suture technique, lid margin split, and LER disinsertion simultaneously for lower eyelid epiblepharon and were followed up for at least 6 months. The mean age of the patients who underwent surgery was 9.5 (5-28) years. The mean observation period was 8.3 (6-27) months. Recurrence was observed in one eyelid (1.6%). The complications included an ectopic eyelash on one eyelid (1.6%). LER disinsertion performed in this study had two advantages. First, the imbalance between the anterior and posterior lamellae was corrected. Disinserting the LER, the tarsal plate could be repositioned cranially, effectively addressing this imbalance. Second, LER disinsertion ensured direct exposure of the lower margin of the tarsal plate, facilitating the implementation of a reliable rotating suture. In conclusion, promising results were achieved by combining the rotating suture technique with LER disinsertion and lid margin splitting.

Ultrasonographic Characteristics in the Fingers and Other Superficial Glomus Tumours.

Glomus tumours are painful superficial tumours, and ultrasonography is an extremely useful and noninvasive diagnostic technique for superficial organs. In this study, we retrospectively examined glomus tumours using ultrasonography. Among 18 patients histopathologically diagnosed with glomus tumours via ultrasonography, we observed five different development sites: subungual areas or those surrounding the nail bed (12), other areas on the finger surface (3), abdominal wall (1), upper arm (1), and forearm (1). The ultrasonographic images revealed significant differences in tumour size, indicating that tumours on other body surfaces tended to be smaller than those on patients' fingers (p < 0.01). The depth/width ratios of tumours on the other body surfaces were significantly higher than those on the fingers (p < 0.05). The tumours showed a regular shape (72.2%) and clear border (100%). Furthermore, most tumours were low-echo tumours with a diameter of up to 15 mm, clear margins, and no lateral shadows. Abundant blood flow and vessels in and out of the tumours were also observed. In conclusion, our study describes the ultrasonographic characteristics of glomus tumours and reveals that they cannot be ruled out when diagnosing small painful subcutaneous tumours.

Comparison of postoperative recurrence rates between percutaneous and transconjunctival approaches for involutional entropion.

Lower eyelid entropion is the second most common disease seen after ptosis in oculoplastic outpatients. In this study, we performed percutaneous and transconjunctival shortening of the anterior and posterior layers of the lower eyelid retractor (LER) to treat lower eyelid involutional entropion. This study aimed to examine the recurrence rate and complications of the percutaneous and transconjunctival approaches. This was a retrospective study of procedures conducted from January 2015 to June 2020. The LER shortening was performed for lower eyelid involutional entropion on 103 patients (116 eyelids). From January 2015 to December 2018, LER shortening using the percutaneous approach was implemented; from January 2019 to June 2020, the transconjunctival approach was used to shorten the LER. All patient charts and photographs were retrospectively reviewed. Recurrence occurred in 4 patients (4.3%) in the percutaneous approach. No recurrence was observed in any patient in the transconjunctival approach. Temporary ectropion occurred in 6 patients (7.6%) when the percutaneous approach was used; all cases healed within 3 months after surgery. The study did not reveal any statistically significant difference in recurrence rates between the percutaneous and transconjunctival approaches. We achieved results equal to or better than percutaneous LER shortening by combining transconjunctival LER shortening with horizontal laxity shortening, such as lateral tarsal strip, pentagonal resection, and orbicularis oculi muscle resection. However, it is necessary to be careful about temporary ectropion after surgery when percutaneous LER shortening alone is performed for lower eyelid entropion.

Association between Diabetic Peripheral Neuropathy as Measured Using a Point-of-Care Sural Nerve Conduction Device and Urinary Albumin Excretion in Patients with Type 2 Diabetes.

BACKGROUND: It is not well known whether diabetic peripheral neuropathy diagnosed using a non-invasive point-of-care nerve conduction device called DPN-Check® is associated with diabetic nephropathy. Thus, we aimed to evaluate the association of diabetic peripheral neuropathy with urinary albumin excretion in patients with type 2 diabetes using DPN-Check®. METHODS: This retrospective observational study included 323 Japanese patients with type 2 diabetes. The urinary albumin-to-creatinine ratio in a spot urine sample was defined as urinary albumin excretion. Multiple linear regression analysis was used to determine the association of DPN-Check®-determined diabetic peripheral neuropathy with urinary albumin excretion. RESULTS: Patients with DPN-Check®-determined diabetic peripheral neuropathy had significantly higher urinary albumin excretion than those without, while there was no difference in urinary albumin excretion between patients with and without diabetic peripheral neuropathy determined by simplified diagnostic criteria. In the multivariate model, the DPN-Check® determined that diabetic peripheral neuropathy was significantly associated with urinary albumin excretion even after adjustment for covariates (standardized ß, 0.123; p = 0.012). CONCLUSIONS: Our study found a significant association between diabetic peripheral neuropathy diagnosed using DPN-Check® and urinary albumin excretion in patients with type 2 diabetes.

Clinical utility of artificial intelligence assistance in histopathologic review of lymph node metastasis for gastric adenocarcinoma.

BACKGROUND: Advances in whole-slide image capture and computer image analyses using deep learning technologies have enabled the development of computer-assisted diagnostics in pathology. Herein, we built a deep learning algorithm to detect lymph node (LN) metastasis on whole-slide images of LNs retrieved from patients with gastric adenocarcinoma and evaluated its performance in clinical settings. METHODS: We randomly selected 18 patients with gastric adenocarcinoma who underwent surgery with curative intent and were positive for LN metastasis at Chiba University Hospital. A ResNet-152-based assistance system was established to detect LN metastases and to outline regions that are highly probable for metastasis in LN images. Reference standards comprising 70 LN images from two different institutions were reviewed by six pathologists with or without algorithm assistance, and their diagnostic performances were compared between the two settings. RESULTS: No statistically significant differences were observed between these two settings regarding sensitivity, review time, or confidence levels in classifying macrometastases, isolated tumor cells, and metastasis-negative. Meanwhile, the sensitivity for detecting micrometastases significantly improved with algorithm assistance, although the review time was significantly longer than that without assistance. Analysis of the algorithm's sensitivity in detecting metastasis in the reference standard indicated an area under the curve of 0.869, whereas that for the detection of micrometastases was 0.785. CONCLUSIONS: A wide variety of histological types in gastric adenocarcinoma could account for these relatively low performances; however, this level of algorithm performance could suffice to help pathologists improve diagnostic accuracy.

Cerebellar tonsillar herniation in sudden death of an adolescent anorexia nervosa patient: a case report.

BACKGROUND: Anorexia nervosa not only results in severe malnutrition but also carries a high risk of sudden death. Although fatal arrhythmias are the most common cause of sudden death, it is often unclear what exactly causes them. To the best of our knowledge, there have been no reports of cerebellar tonsillar herniations in patients with anorexia nervosa. CASE PRESENTATION: A 17-year-old girl with anorexia nervosa and autism spectrum disorder was admitted to the pediatric ward for extreme weight loss. Since she refused to take oral nutrition or tube feeding, we started continuous intravenous fluids. Eight hours after admission, she suddenly went into cardiopulmonary arrest and died despite resuscitation. A postmortem autopsy revealed the unexpected findings of generalized severe cerebral edema and cerebellar tonsillar herniation. CONCLUSION: Intracranial hypertension may need to be considered when the condition of patients with anorexia nervosa suddenly worsens during refeeding periods. Postmortem autopsy and autopsy imaging are recommended to determine the exact cause of sudden death. LEVEL OF EVIDENCE: Level IV: Evidence obtained from multiple time series analysis such as case studies. (NB: Dramatic results in uncontrolled trials might also be regarded as this type of evidence).

Role of Early Serial Renal Transplant Allograft Protocol Biopsies in Living Kidney Transplantations.

PURPOSE: This study aimed to analyze the incidence of subclinical rejection (SCR) in kidney transplantation patients and risk factors associated with SCR. METHODS: We assessed 80 protocol biopsies taken within 2 years postoperatively in 41 adult patients who underwent living donor kidney transplantation between 2017 and 2020. All patients were on immunosuppressant therapy that included tacrolimus, mycophenolate mofetil, and steroids. RESULTS: The prevalence of Banff Borderline classification at 3, 6, and 12 months after transplantation was 4%, 5%, and 8 %, respectively, whereas none of the biopsies met the Banff criteria for acute T cell-mediated rejection throughout the study period. Active antibody-mediated rejection (ABMR) was only present in 8% of patients at 3 months after transplantation and chronic active ABMR at 6, 12, and 24 months after transplantation was detected in 10%, 13%, and 11% of the patients, respectively. Subgroup analysis revealed that 50% of the 6 patients with preformed anti-donor specific antibodies (DSAs) developed clinical or subclinical active ABMR within 3 months after transplantation, followed by chronic active ABMR according to serial histologic assessment. Conversely, only a small proportion of patients (3%) without preformed DSAs exhibited clinically active ABMR. CONCLUSIONS: SCR occurs too infrequently in patients with low immunologic risk and strong contemporary immunosuppression therapy to justify the diagnostic effort of serial protocol biopsies. However, protocol biopsies remain an indispensable tool in renal transplant monitoring and may be especially important in immunologically high-risk patients with pre-existing DSAs.

A case of proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) that responded favorably to steroid therapy.

Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) generally has a poor prognosis and the consensus is that it needs to be treated with clone-directed therapy. However, the prognosis of PGNMID is heterogenous and some cases have been successfully treated using other therapeutic strategies. We herein report a case of PGNMID that responded favorably to steroids without clone-directed therapy. An 18-year-old woman was referred to a nephrologist with proteinuria detected in an annual health check-up. Over a 3-year period, the concentration of creatinine (Cr) increased from 0.76 to 1.00 mg/dL and proteinuria from 0.35 to 1.9 g/g Cr. Monoclonal gammopathies were not detected in her serum or urine. Based on the findings of kidney biopsy at the age of 21 years, the patient was diagnosed with proliferative glomerulonephritis with monoclonal IgG1-kappa deposits. The histological feature was mesangial proliferative glomerulonephritis with advanced glomerulosclerosis, which is a rare presentation of PGNMID. Intravenous methylprednisolone pulse therapy was initiated, followed by oral prednisolone at a dose of 30 mg daily. One year later, a second kidney biopsy revealed a significant decrease in mesangial deposits of IgG1-kappa. Prednisolone was gradually tapered and discontinued 2 years after the first kidney biopsy. At the time of prednisolone withdrawal, urinalysis showed proteinuria of 0.2 g/g Cr without hematuria. Kidney function remained stable throughout the treatment period.

Effects of Fat Repositioning for Tear Trough Deformity on Eye Movement.

ABSTRACT: Fat repositioning is a common surgical technique for treating tear trough deformity. As this technique is mainly performed for cosmetic purposes, its functional outcomes have rarely been evaluated. The purpose of this study was to evaluate the changes in eye movements that occur after fat repositioning for tear trough deformity. The authors performed fat repositioning on 18 eyelids of 9 patients and evaluated their eye movements and binocular vision before surgery and at 1, 3, and 6 months after surgery. Hess screen and Binocular single vision tests were performed during each follow-up examination and the scores were recorded. The authors observed that fat repositioning did not affect binocular vision; however, vertical and horizontal eye movements worsened at 3 months after surgery. Nevertheless, there was no significant difference between the eye movements recorded before surgery and those recorded 6 months after surgery. Regardless of this finding, it should be noted that vertical or horizontal strabismus might occur after fat repositioning for tear trough deformity.

Anti-MDA5 Antibody-positive Dermatomyositis with Rapidly Progressive Interstitial Pneumonia Presenting with Nephrotic Syndrome during Treatment with Corticosteroids and Cyclosporine.

A 50-year-old Japanese woman with anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 antibody)-positive dermatomyositis presenting with rapidly progressive interstitial pneumonia was treated with corticosteroids and cyclosporine. She developed nephrotic syndrome during the treatment regimen with corticosteroids and cyclosporine. A kidney biopsy revealed a thrombotic microangiopathy (TMA) glomerular lesion. Anti-MDA5 antibody-positive dermatomyositis is prone to severe interstitial lung disease (ILD) and is often exacerbated and refractory to treatment. Renal symptoms might be due to TMA of the kidney, and this may be a sign that more intensive treatment is needed. Patients sometimes develop acute kidney injury, which may be due to the TMA.

Comparison between the effects of normal saline with and without heparin for the prevention and management of arterial catheter occlusion: a triple-blinded randomized trial.

PURPOSE: We aimed to compare the effects of saline with and without heparin on the catheter-occlusion rate and coagulation-related blood test results for the management of arterial catheters among patients admitted to a short-term intensive care unit postoperatively. METHODS: This prospective, triple-blinded, randomized controlled study recruited patients aged 20-90 years scheduled to undergo radial arterial catheter insertion and postoperative intensive care unit admission between February and August 2019. Patients were randomly allocated to two groups (1:1 ratio) depending on the use of heparin: study (normal saline with heparin, 3000 units to 500 ml of normal saline) and control (normal saline without heparin) groups with arterial catheters. The allocated management method was employed immediately after intensive care unit admission. Occlusion assessment (every 12 h), arterial blood gas tests (every 6 h), and blood sample collection (every 24 h) were performed. The occlusion of arterial catheter was assessed using occlusion rate, and blood test results were assessed using a linear mixed model. RESULTS: There were 147 patients in the arterial catheter groups. There were no significant differences in occlusion rates and changes in platelet counts and activated partial thromboplastin time between the groups with arterial (p = 0.98, 0.16, and 0.32, respectively) catheters during the first 6 days after intensive care unit admission. CONCLUSION: Normal saline with and without heparin showed similar efficiency for both the prevention of occlusion and the results of coagulation.

Comparison of postoperative recurrence rates between levator aponeurosis advancement and external Müller's muscle tucking for acquired blepharoptosis.

Treatment options for acquired blepharoptosis include levator resection, levator aponeurosis advancement (LAA), Müller's muscle-conjunctival resection (MMCR), and frontalis suspension. Previously, we reported a technique called external Müller's muscle tucking (EMMT) using the Müller's muscle as a power source. In this study, we compare LAA with EMMT and evaluate the recurrence and reoperation rates. LAA was performed on 96 eyelids in 51 patients. The average follow-up period was 12.2 months, recurrence occurred in four eyelids (4.2%) of three patients, and reoperation was required in one eyelid of one patient (2.0%). EMMT was performed on 94 eyelids in 51 patients, the mean follow-up period was 10.5 months, recurrence occurred in 14 eyelids (15%) of 10 patients, and reoperation was required in three eyelids of two patients (3.9%). A comparison of LAA and EMMT recurrence showed that EMMT was associated with a significantly higher recurrence rate (P = 0.0021). The causes of EMMT recurrence included thinning and fatty degeneration of Müller's muscles, necrosis of ligated Müller's muscles, and less postoperative scar formation. There was no correlation between EMMT recurrence and the severity of the blepharoptosis.

Combination of Dermal fat Grafting and Frontalis Suspension Using Polytetrafluoroethylene Sheet for Blepharoptosis With a Deep Sulcus.

ABSTRACT: The frontalis suspension procedure is a common surgical method for patients with severe blepharoptosis. While frontalis suspension is a very effective method, the transplant material may be visualized after surgery in patients with a deep sulcus and severe blepharoptosis. To prevent this complication, we performed a combination of dermal fat grafting and frontalis suspension using a polytetrafluoroethylene sheet in 5 patients (6 eyelids). We followed-up the patients for at least 6 months postoperatively (mean: 6.8 months) and observed no transplant material visualization or occurrence of infection. The mean pre- and postoperative margin reflex distance-1 was -3.75 (-5 to -2) and 2.10 (1-3), respectively. Bulky upper eyelids were observed 6 months postoperatively in 1 patient (2 eyelids). None of the patients underwent reoperation. In conclusion, the combination of frontalis suspension using a polytetrafluoroethylene sheet and dermal fat grafting for severe blepharoptosis and a deep upper eyelid sulcus was effective in preventing visualization of the transplant material.

Histopathologic Change of a Case of Gastric Oxyntic Neoplasm (Gastric Adenocarcinoma of Fundic Gland Mucosa Type) Through 5 Years With Concurrent Other Oxyntic Gland Lesions.

Some gastric epithelial neoplasms show predominant chief cell differentiation (oxyntic gland neoplasms), in which the entity of "gastric adenocarcinoma of fundic gland type" was firstly designated, whereas a possible more aggressive subgroup "gastric adenocarcinoma of fundic gland mucosa type" (GA-FGM) was subsequently proposed. However, the histopathologic progression mode of these neoplasms has not been sufficiently reported. In this article, we describe a case of GA-FGM in which we could observe its progression during 5 years. The tumor was removed by endoscopic submucosal dissection 5 years after the first biopsy, which had already shown a feature of oxyntic gland neoplasm. During the follow-up period, the endoscopy revealed little change in the tumor appearance. However, the histology of endoscopic submucosal dissection showed submucosal extension with its histological progression. Besides, other oxyntic gland neoplasms of the stomach were observed metachronously or synchronously, giving an implication about a common pathogenetic basis of these lesions.

A New Surgical Method for Medial Ectropion Repair: Fixing the Lower Eyelid Retractor to the Back of the Tarsal Plate.

ABSTRACT: Involutional ectropion is a disease in which the eyelids are everted outwards, and because the eyelids move away from the eyeballs, the ocular surface and conjunctiva are exposed causing inflammation, pain, photophobia, foreign body sensation, epiphora, and blurred vision. It is thought to be caused by horizontal and vertical laxity. Various surgical methods have reportedly been used to correct involutional ectropion. Shortening the lower eyelid retractor (LER) is an indispensable surgical operation for medial ectropion. When the LER is shortened, it is usually fixed to the lower edge of the tarsal plate. Herein we describe a new type of surgery that has now been performed on 6 eyes in 4 patients. The procedure involves separating the conjunctiva from the tarsal plate, inserting the LER between the conjunctiva and the tarsal plate, and then fixing it to the back of the tarsal plate. In all 6 eyes, the lower eyelid now contacts the eyeball, and morphological improvements were achieved. This new surgical method is a useful way to raise the tarsal plate.

Gingival Sulcus Incision for Zygomaticomaxillary Complex Fracture.

The usual surgical approaches for zygomaticomaxillary complex fracture are subciliary incision, transconjunctival incision, eyebrow incision, lateral canthal incision, coronal incision, preauricular incision, and superior gingivobuccal incision. In the intraoral approach, a horizontal mucoperiosteal incision is performed at the superior gingivobuccal region, and sometimes, includes the upper labial frenum. This may cause discomfort in the oral cavity because of postoperative scarring and shortening of the upper labial frenum. To avoid these complications, the authors performed a novel approach using gingival sulcus incision instead of oral mucosal incision to treat 5 zygomatic fractures. The authors evaluated the regression of the gingival interdental papillae, gingival swelling, and gingival perception at 2 weeks, 1 month, 3 months, and 6 months after the operation. The regression of the gingival papillae and gingival swelling disappeared 3 months and 1 month after the operation, respectively. No paresthesia was observed in any of the cases. The gingival sulcus approach can lead to scarless results and contribute considerably to the aesthetic appearance of the oral cavity.

[The association between alcohol consumption and Mild Cognitive Impairment: the Toon Health Study].

AIM: The effects of alcohol consumption on Mild Cognitive Impairment (MCI) among the Japanese population had not been fully examined. Therefore, the objective of this study was to examine the association between alcohol consumption and MCI among the Japanese elderly population. METHODS: In total, 421 men and 700 women aged 60-84 years participated in this cross-sectional study. Alcohol consumption was estimated according to frequency and amount of major alcoholic beverages (i.e., beer, Japanese sake, shochu, and wine) consumed by each individual using a self-administered questionnaire. MCI was assessed using the Japanese version of the Montreal Cognitive Assessment. Multivariable odds ratio (OR) and 95% confidence intervals (CIs) of MCI according to alcohol consumption were calculated using logistic models. We further analyzed the associations of the major alcoholic beverages with MCI. RESULTS: The prevalence of MCI was 50.4% among the male participants and 31.4% among the females. A positive association between alcohol consumption and MCI was observed in men, but not in women. The multivariable OR (95% CI) of MCI for ≥ 2 go (46 g ethanol) /day vs. non-drinkers was 1.78 (0.93-3.40, p for trend = 0.045) in men and for ≥ 1 go (23 g ethanol) /day was 0.96 (0.39-2.38, p for trend = 0.92) in women, respectively. We also observed an association between shochu consumption and MCI in men, whereby the multivariable OR (95% CI) of MCI for each 1 go increment was 1.57 (1.18-2.07). CONCLUSION: Our findings suggest that alcohol consumption in moderation may contribute to the prevention of MCI development in men.

A Randomized Phase 2 Trial of Antibiotic Prophylaxis Versus No Intervention for Muscle Biopsy in A Neurology Department.

Muscle biopsy can be used to confirm the diagnosis of neuromuscular diseases. However, it is unclear whether antibiotic prophylaxis prior to muscle biopsy is needed to prevent surgical site infection (SSI). We are conducting a phase 2, single-center, open-labeled, prospective randomized trial to clarify the need for antibiotic prophylaxis in patients at low risk for SSI undergoing muscle biopsy. Patients will be randomized to an antibiotic prophylaxis group or a control group, and the incidence of SSI will be compared between the groups. Our findings will clarify the need for antibiotic prophylaxis in this patient population.