[A case of subphrenic abscess in a very elderly patient relieved by conservative treatment].

A patient in her 90s with rheumatoid arthritis was admitted to the hospital. She was brought to the emergency department with a complaint of a fever and diagnosed with a urinary tract infection on admission, and antimicrobial therapy was started. On day 8 of admission, abdominal ultrasonography revealed a right subphrenic abscess due to cholecystitis with perforation. The patient consulted with the Department of Surgery, but drainage was deemed difficult due to the anatomical location of the gallbladder, and conservative treatment with antibiotics was continued. After two months of intravenous antimicrobial therapy, the abscess shrank, and the patient was discharged from the hospital after switching to oral antimicrobial therapy. At a follow-up visit two weeks after discharge, the abscess was confirmed to have disappeared, the oral antimicrobial therapy was discontinued, with no abscess recurrence noted. The principle of treatment for subphrenic abscess is the administration of broad-spectrum antimicrobial agents that cover enterobacteria and anaerobes, and drainage at appropriate times. Indeed, drainage is performed in most of the reported cases of subphrenic abscesses. However, in very elderly patients or those in whom puncture is difficult, conservative treatment while carefully checking imaging findings and other potentially involved factors may be an option.

Seizure-related stress and arousal responses mediate a relationship between anxiety trait and state in epilepsy.

BACKGROUND: Epilepsy causes substantial psychological distress and anxiety, primarily due to seizures. However, the impact of stress responses and changes in arousal and their association with anxiety patterns in patients with epilepsy (PWE) remains unclear. This study aimed to investigate the relationships among seizures, stress and arousal characteristics, and trait and state anxiety characteristics in PWE. METHODS: Our sample consisted of 159 outpatients with epilepsy recruited from five institutions in Japan in 2020. Participants completed the State-Trait Anxiety Inventory-Form JYZ (STAI) and the Japanese-Stress Arousal Check List (J-SACL). We analyzed the correlations between inventory scores and clinical information. Using principal component analysis (PCA), we derived epilepsy-specific stress/arousal characteristics, which accounted for high arousal and low-stress levels, termed epilepsy-specific stress or arousal response (ESAR), from the J-SACL scores. We conducted a mediation analysis to assess the mediating role of ESAR in the relationship between traits and state anxiety. RESULTS: We found significant correlations between J-SACL stress and arousal factors (r = -0.845, p < 0.001), ESAR and seizure frequency (r = -0.29, p < 0.001), ESAR and trait anxiety scores on the STAI (r = -0.77, p < 0.0001), and ESAR and state anxiety scores on the STAI (r = -0.60, p < 0.0001). Mediation analysis supported by the Monte Carlo method revealed that ESAR significantly mediated the association between trait and state anxiety. CONCLUSIONS: These findings elucidate the epilepsy-specific stress and arousal characteristics and their roles in mediating traits and state anxiety. These results may reflect the long-term clinical course and unique emotion recognition tendencies in epilepsy.

Impact of MRI on the post-therapeutic diagnosis of T4 esophageal cancer.

BACKGROUND: Opportunities for T4b esophageal cancer patients to receive curative surgery are increasing with the development of multidisciplinary treatments. However, the best modality to accurately diagnose infiltration to the organs surrounding T4b esophageal cancer is still unknown. The aim of this study was to determine the performance of CT and MRI in diagnosing T stage in T4b esophageal cancer, with reference to the pathological diagnosis. METHODS: A retrospective medical records review of patients with T4b esophageal cancer patients from January 2017 to December 2021 was conducted. Among 125 patients who were treated for cT4b esophageal cancer in Osaka University Hospital, 30 patients were diagnosed with cT4b esophageal cancer by CT, ycT staging with CT (contrast-enhanced images) and MRI (T2-FSE images), and curative R0 resection was performed. Preoperative MRI staging was independently performed by two experienced radiologists. The diagnostic performance of CT and MRI were examined using McNemar's test. RESULTS: Nineteen and 12 patients were diagnosed with ycT4b by CT and MRI, respectively. Combined T4b organ resection was performed in 15 patients. A pathological diagnosis of ypT4b was made in 11 cases. In comparison to CT, MRI showed a higher diagnostic performance, specificity (47% vs. 89%, p = 0.013), and accuracy (60% vs. 90%, p = 0.015) for CT vs. MRI. CONCLUSIONS: Our results-with reference to the pathological diagnosis-revealed that MRI had a superior diagnostic performance to CT for diagnosing T4b esophageal cancer invading the surrounding organs. An accurate diagnosis of T4b esophageal cancer may facilitate the implementation of appropriate treatment strategies.

[A case of bacterial meningitis due to colon perforation of V-P shunt tube in an elderly patient with prolonged high fever after hospitalization for urinary tract infection].

An 86-year-old woman who had received a V-P shunt for subarachnoid hemorrhage 23 years previously presented to the emergency room with a chief complaint of fever. The diagnosis on admission was urinary tract infection, and treatment with CMZ was started. Abdominal CT scan on admission revealed that the V-P shunt had penetrated the ascending colon; however, because there were no clinical symptoms or imaging findings suggestive of peritonitis or meningitis, the V-P shunt was not initially considered to be related to the fever. However, since the fever in the 39°C range persisted for a week despite a urine culture showing susceptible Escherichia coli, a spinal fluid examination was performed on the assumption of meningitis caused by the V-P shunt. We found elevated cell counts in the CSF and diagnosed the patient with bacterial meningitis. After shunt removal surgery was performed, the patient quickly recovered from fever. Later, Pseudomonas aeruginosa was detected at the shunt tube and in the CSF, and CFPM was administered continuously. The patient was discharged with good progress.A review of the relevant literature revealed that half of the patients with a V-P shunt penetrating the intestinal tract will pass asymptomatically and are unlikely to develop peritonitis, while half of the patients may develop meningitis. In addition, if there is an artifact in the body, it is always necessary to consider the possibility that it may be the source of infection.

Understanding psychiatric illness through natural language processing (UNDERPIN): Rationale, design, and methodology.

Introduction: Psychiatric disorders are diagnosed through observations of psychiatrists according to diagnostic criteria such as the DSM-5. Such observations, however, are mainly based on each psychiatrist's level of experience and often lack objectivity, potentially leading to disagreements among psychiatrists. In contrast, specific linguistic features can be observed in some psychiatric disorders, such as a loosening of associations in schizophrenia. Some studies explored biomarkers, but biomarkers have yet to be used in clinical practice. Aim: The purposes of this study are to create a large dataset of Japanese speech data labeled with detailed information on psychiatric disorders and neurocognitive disorders to quantify the linguistic features of those disorders using natural language processing and, finally, to develop objective and easy-to-use biomarkers for diagnosing and assessing the severity of them. Methods: This study will have a multi-center prospective design. The DSM-5 or ICD-11 criteria for major depressive disorder, bipolar disorder, schizophrenia, and anxiety disorder and for major and minor neurocognitive disorders will be regarded as the inclusion criteria for the psychiatric disorder samples. For the healthy subjects, the absence of a history of psychiatric disorders will be confirmed using the Mini-International Neuropsychiatric Interview (M.I.N.I.). The absence of current cognitive decline will be confirmed using the Mini-Mental State Examination (MMSE). A psychiatrist or psychologist will conduct 30-to-60-min interviews with each participant; these interviews will include free conversation, picture-description task, and story-telling task, all of which will be recorded using a microphone headset. In addition, the severity of disorders will be assessed using clinical rating scales. Data will be collected from each participant at least twice during the study period and up to a maximum of five times at an interval of at least one month. Discussion: This study is unique in its large sample size and the novelty of its method, and has potential for applications in many fields. We have some challenges regarding inter-rater reliability and the linguistic peculiarities of Japanese. As of September 2022, we have collected a total of >1000 records from >400 participants. To the best of our knowledge, this data sample is one of the largest in this field. Clinical Trial Registration: Identifier: UMIN000032141.

Comparison of the occurrence of sleep bruxism under accustomed conditions at home and under polysomnography conditions in a sleep laboratory.

PURPOSE: We aimed to clarify the relationship between the number of sleep bruxism (SB) bursts at home and in a laboratory equipped with polysomnography with audio-video recording (PSG-AV). We applied an identical single-channel wearable electromyography (EMG) device for both types of SB burst scorings. METHODS: The subjects were 20 healthy student volunteers (12 men and 8 women; mean age, 21.9 years) who were clinically diagnosed with bruxism based on the criteria set forth by the International Classification of Sleep Disorders (ICSD-2). We used a wearable EMG device attached to the masseteric area (the FLA-500-SD [FLA]), for scoring SB bursts at home and in the laboratory. PSG-AV was set within the laboratory environment as well. The mean interval for both sleep studies was 28.8 days. EMG bursts with amplitudes greater than twice the baseline amplitude and with durations of longer than 0.25 s were selected. EMG bursts with amplitudes ≥5% MVC (maximum voluntary contraction), ≥10% MVC, and ≥20% MVC were selected as well. A cluster of bursts was defined as an episode. RESULTS: In all the conditions for selecting EMG bursts specified above, the number of SB bursts and episodes recorded under laboratory conditions was statistically significantly smaller than that recorded at home. There were no statistically significant differences between the data obtained on the first and second recording days. CONCLUSION: The results of this study suggest that the unfamiliar environment of a sleep laboratory equipped with PSG-AV affects the emergence of SB as compared with home conditions.

Minimum measurement time of masseteric electromyogram required for assessment of awake bruxism during the daytime.

Objective: Assessments of diurnal awake bruxism (d-AB) using masseteric electromyogram (EMG) during various lengths of measurement time within a day were examined as the first step of research to clarify the minimum measurement time required for assessment of d-AB by subject.Methods: Subjects were 33 outpatients. Assessment of d-AB by EMG during partial measurement time (PMT) with durations ranging from 30 minutes to 6 hours was compared with that during total measurement time (TMT) used as the reference standard.Results: No significant difference was found between TMT data and PMT data. There were significant correlations in all combinations between TMT data and PMT data. Accuracy was 0.909 or more for 2.5 hours or longer.Discussion: The results suggest that the tendency of daytime muscle activity in 1 day can be assessed even by using masseteric EMG data obtained during a relatively short measurement time.

Quantitative analyses of jaw-opening muscle activity during the active phase of jaw-closing muscles in sleep bruxism.

Rhythmic masticatory muscle activity (RMMA), which is defined as three or more consecutive phasic bursts, accounts for a large part of sleep bruxism (SB). RMMA is thought to be characterized by co-contraction, a jaw muscle activity in which jaw-opening muscles contract during the active phase of jaw-closing muscles, which is different from that during mastication. However, there has been limited information about co-contraction. The aim of the present study was to clarify the amplitudes and patterns of jaw-opening muscle activity during the active phase of jaw-closing muscles in RMMA. Data from 14 healthy volunteers with bruxism, which was diagnosed by using polysomnographic recording with audio-video, were analysed. RMMA with electromyographic amplitudes of more than two times the baseline amplitude was selected. From the selected RMMA, burst groups consisting of five or more consecutive phasic bursts, including tonic bursts, were selected for analyses. Electromyographic activities during gum chewing were also recorded before sleeping. The minimum, maximum and average value of the amplitudes of jaw-opening muscle activity during the active phase of jaw-closing muscles were calculated. Jaw-opening muscle activity during the active phase of jaw-closing muscles in RMMA was closer to the baseline than that in gum chewing. The minimum, maximum and average values of amplitudes of jaw-opening muscle activity during the phase were significantly smaller than those of gum chewing. Contrary to our hypothesis prior to the study, the obtained results suggested that the pattern of electromyogram activity of jaw-opening and jaw-closing muscles in RMMA was not necessarily co-contraction.

Validity of single-channel masseteric electromyography by using an ultraminiature wearable electromyographic device for diagnosis of sleep bruxism.

PURPOSE: The purpose of this study was to clarify the validity of assessment of sleep bruxism (SB) by using single-channel electromyogram (EMG) and a cut-off value with optimum sensitivity and specificity. METHODS: The subjects were twenty volunteers with clinical diagnosis of SB. Assessment by masseteric EMG data only by using a wearable EMG was compared with reference standard assessment by masseteric EMG data using polysomnography with audio-visual recording (PSG-AV). From EMG activities recorded by single-channel EMG, bursts of more than two times the baseline amplitude with a duration of 0.25s or more were selected by a burst unit (EMG-burst-all). Furthermore, from EMG-burst-all, bursts that were more than 5-20% of the maximum voluntary contraction value (EMG-burst-5%, EMG-burst-10%, EMG-burst-20%) were selected. By an episode unit, phasic, tonic, and mixed episodes were selected by single-channel EMG (EMG-episodes). Among the EMG-episodes, further, reference standard episodes of SB (PSG-episodes) were selected by PSG-AV assessment. RESULTS: Sixteen subjects were diagnosed as bruxers based on PSG-AV (PSG-episodes/h >2). By a burst unit and an episode unit, there were significant correlations between assessment variables of SB by single-channel EMG and PSG-AV except for EMG-burst-20%/h. When the cut-off value in EMG-episodes/h was 5.5/h for sleep bruxers, both sensitivity and specificity were 100%. As for variables by a burst unit, EMG-burst-all/h and EMG-burst-5% had higher values of sensitivity and specificity. CONCLUSIONS: The results suggested that single-channel EMG is valid for diagnosis of SB if a cut-off value that is appropriate for single-channel EMG is used.

Overview of Biological, Epidemiological, and Clinical Evidence of Radiation Hormesis.

The effects of low-dose radiation are being increasingly investigated in biological, epidemiological, and clinical studies. Many recent studies have indicated the beneficial effects of low doses of radiation, whereas some studies have suggested harmful effects even at low doses. This review article introduces various studies reporting both the beneficial and harmful effects of low-dose radiation, with a critique on the extent to which respective studies are reliable. Epidemiological studies are inherently associated with large biases, and it should be evaluated whether the observed differences are due to radiation or other confounding factors. On the other hand, well-controlled laboratory studies may be more appropriate to evaluate the effects of low-dose radiation. Since the number of such laboratory studies is steadily increasing, it will be concluded in the near future whether low-dose radiation is harmful or beneficial and whether the linear-no-threshold (LNT) theory is appropriate. Many recent biological studies have suggested the induction of biopositive responses such as increases in immunity and antioxidants by low-dose radiation. Based on recent as well as classical studies, the LNT theory may be out of date, and low-dose radiation may have beneficial effects depending on the conditions; otherwise, it may have no effects.

In vivo evaluation of cisplatin-loaded superabsorbent polymer microspheres for use in chemoembolization of VX2 liver tumors.

PURPOSE: To investigate the pharmacokinetics and efficacy of chemoembolization with a cisplatin-loaded superabsorbent polymer (SAP) suspension in a rabbit model with transplanted liver VX2 tumors. MATERIALS AND METHODS: VX2 tumors were implanted into the left lobe of the liver in eight rabbits. Embolization of the proper hepatic artery was performed with cisplatin-loaded or unloaded SAP. In the cisplatin-loaded SAP group (n = 4), 5 mg of SAP (106-150 µm) loading 2.35 mg of cisplatin and 0.5 mL of ionic contrast material (ioxaglic acid 320 mgI/mL) was injected into the proper hepatic artery. In the control group (hepatic arterial infusion [HAI] + SAP; n = 4), 5 mg of SAP loading 0.5 mL of ioxaglic acid alone was injected after a bolus infusion of an equivalent amount of cisplatin. Sequential change of the plasma platinum concentration within the first 24 hours was measured. Blood sampling and histopathologic examination were performed at 1-week follow-up. Magnetic resonance (MR) images were used to calculate the growth rate of the VX2 tumor. RESULTS: All animals underwent successful embolization. Both total and free plasma platinum mean concentrations within the first 24 hours remained lower in the cisplatin-loaded SAP group, although without statistical significance (P > .05). The mean tumor growth rate was significantly lower in the cisplatin-loaded SAP group than the control group (20% vs 116%; P = .049). Histopathologic examination revealed coagulative necrosis to nontumorous liver parenchyma in two rabbits in the cisplatin-loaded SAP group, although no deaths occurred. CONCLUSIONS: These results suggested that chemoembolization with cisplatin-loaded SAP was a safe and tolerable treatment and was more effective in suppressing the tumor growth.

Transarterial chemoembolization with cisplatin as second-line treatment for hepatocellular carcinoma unresponsive to chemoembolization with epirubicin-Lipiodol emulsion.

PURPOSE: The purpose of this retrospective study was to investigate the efficacy of transarterial chemoembolization (TACE) using cisplatin as a second-line treatment for advanced hepatocellular carcinoma (HCC) unresponsive to TACE using epirubicin-Lipiodol emulsion at our institution. MATERIALS AND METHODS: Between January 2006 and March 2009, 51 patients with unresectable HCC underwent TACE using cisplatin. All patients had shown persistent viable tumor or tumor progression after at least 2 sessions of TACE using epirubicin-Lipiodol emulsion. TACE procedures consisted of arterial injection of a mixture of Lipiodol and cisplatin (30-100 mg [mean 57 ± 21]) (n = 29) or arterial infusion of cisplatin (30-100 mg [mean 87 ± 19]) solution (n = 22) followed by injection of 1-mm porous gelatin particles. Early tumor response was assessed by contrast-enhanced computed tomography (CT) according to Response Evaluation Criteria in Solid Tumors (RECIST) and European Association for the Study of the Liver (EASL) criteria. Overall survival and progression-free survival was calculated using the Kaplan-Meier method. Toxicity was assessed according to NCI-CTCAE version 3 criteria. RESULTS: Response rates were 11.8 and 27.5% by RECIST and EASL criteria, respectively. Overall survival rates were 61.9, 48.2, and 28.9% at 1, 2, and 3 years, respectively, and the median survival time was 15.4 months. Progression-free survival rate was 35.2% at 1 year, and median progression-free survival time was 3.1 months. No major complications were observed, and the occurrence of postembolization syndrome was minimal. Grade 3 to 4 toxicities included thrombocytopenia (5.8%), increased aspartate aminotransferase (AST) level (35.3%), and increased alanine aminotransferase (ALT) level (23.5%). CONCLUSION: Switching the TACE anticancer drug from epirubicin to cisplatin might be the feasible option for advanced HCC, even when considered resistant to the initial form of TACE.

Correlations between aorto-popliteal bolus transit speed and aortic and popliteal bolus transit time during CT angiography of aortoiliac and lower extremity arteries.

PURPOSE: The purpose of this study was to investigate correlations between the aorto-popliteal bolus transit speed and aortic and popliteal bolus transit time in order to evaluate the possibility for prediction of bolus transit speed by single test injection technique. MATERIALS AND METHODS: Approval was obtained from our institutional review board for this study, which included 42 patients, from all of whom written informed consent was obtained. Low-dose serial CT scanning after injection of 12 ml contrast material (300 mg/ml) at a rate of 3 ml/s followed by saline flush was performed twice, first at the level of the upper abdomen and second at the level of the knee joint. The times needed to reach peak enhancement of the upper abdominal aorta (T-aorta) and bilateral popliteal arteries (T-popliteal) were obtained, and aorto-popliteal bolus transit speeds between the abdominal aorta and popliteal arteries were calculated. ABI was recorded for the bilateral feet. The Pearson's product-moment correlation coefficient was used to investigate the correlation between the bolus transit speed and T-aorta, T-popliteal, ABI, and patient age. RESULT: The respective correlation coefficients for bolus transit speed on the one hand and T-aorta, T-popliteal, ABI, patient age on the other were -0.50, -0.84, 0.36, and -0.52. CONCLUSION: The time to peak enhancement for popliteal arteries showed the strongest correlation with aorto-popliteal bolus transit speeds, and was considered to be the most accurate predictor for aorto-popliteal bolus transit speeds.

Porous gelatin particles for uterine artery embolization: an experimental study of intra-arterial distribution, uterine necrosis, and inflammation in a porcine model.

PURPOSE: We evaluated the location of porous gelatin particles (GP; Gelpart; Nippon Kayaku/Astellas, Tokyo, Japan) within the arterial vasculature and their acute effects on uterine necrosis and inflammation after uterine artery embolization (UAE) in swine. MATERIALS AND METHODS: Adult nonpregnant pigs (n = 6) were allocated to either 1- (n = 3) or 2-mm GP (n = 3). Superselective and bilateral embolization of the uterine arteries was performed. All animals were killed 1 week after UAE. Macroscopic and microscopic findings, including the level of arterial occlusion and their effect on uterine necrosis and inflammation, were analyzed. RESULTS: All UAE procedures were completed without severe complications. The macroscopic necrosis was seen in two animals in the 2-mm group with an extent of <50%. The location of the occluded arteries did not differ significantly between groups. The median diameters of the occluded arteries were 449 microm (95% confidence interval [CI] 417-538 microm) in the 1-mm GP group and 484 microm (95% CI 370-560 microm) in the 2-mm GP group. As for microscopic necrosis, no statistically significant difference was observed. The qualitative inflammatory reaction was significantly greater in the 2-mm GP group than in the 1-mm group (p < 0.001). CONCLUSIONS: Both 1- and 2-mm GP occluded the arteries relevant to the target diameter for UAE in porcine uterus, presumably due to the plastic deformity. Both sizes of GP were associated with limited areas of necrosis; however, evaluation of inflammatory reaction was preliminary. Further study with adequate evaluation of inflammatory reactions is suggested.

Spontaneous splenic rupture due to extensive venous malformation with consumptive coagulopathy: treatment with splenic artery embolization.

Extensive venous malformation (VM) is often associated with chronic consumptive coagulopathy, which may result in bleeding complications. We report herein the case of a 25-year-old man with extensive VM involving the left lower extremity who presented with hypovolemic shock and abdominal distension without abdominal trauma. Abdomen computed tomography revealed splenic rupture with massive hemoperitoneum. He was managed successfully by repeated splenic artery embolization.

Massive bleeding of ruptured metastatic hepatic melanoma treated by transarterial embolization.

Although melanoma frequently metastasizes to the liver, its spontaneous rupture is rare. We report herein an unusual case of a 73-year-old man with rupture of multiple hepatic metastases from scalp melanoma and resulting massive intraperitoneal bleeding, which was successfully controlled by transarterial embolization.

In vitro characterization of cisplatin-loaded superabsorbent polymer microspheres designed for chemoembolization.

PURPOSE: To find appropriate contrast media to load cisplatin into superabsorbent polymer (SAP) and to analyze the absorption and elution kinetics of cisplatin to and from SAP. MATERIALS AND METHODS: Three contrast media-ioxaglic acid 320 mg/mL, iohexol 300 mg/mL, and iopamidol 300 mg/mL-were tested for solubility of a new highly soluble cisplatin powder. The appropriate concentrations of cisplatin were predetermined according to the solubility in each contrast medium. For each concentration, we assessed the cisplatin elution kinetics with an atomic absorption spectrophotometer. The SAP particle diameters (106-150 microm dry size) before and after drug elution were also measured. RESULTS: The concentrations of cisplatin were predetermined as 2.5 mg/mL in ioxaglic acid, 2.5 mg/mL in iohexol, and 5.0 mg/mL in iohexol. At these concentrations, 100 mg of SAP carried 5 mg, 25 mg, and 50 mg of cisplatin dissolved in ioxaglic acid (2.5 mg/mL) and iohexol (2.5 mg/mL and 5.0 mg/mL), respectively. Cisplatin-loaded SAP in ioxaglic acid and iohexol exhibited similar elution profiles, with cisplatin fractions of 15%, 40%, 70%, and 95% at 1, 3, 6, and 24 hours, respectively. By drug elution, the mean particle diameter changed from 0.31 mm to 0.61 mm in ioxaglic acid (2.5 mg/mL), from 0.54 mm to 0.60 mm in iohexol 2.5 mg/mL, and from 0.63 mm to 0.59 mm in iohexol 5.0 mg/mL. CONCLUSIONS: SAP was confirmed to absorb and elute cisplatin within 24 hours. When mixed with iohexol, SAP carried a ten times larger dose of cisplatin and expanded twice as large as when mixed with ioxaglic acid. Cisplatin-loaded SAP may have potential as a drug delivery system for the clinical treatment of liver tumors.