A Novel Hemostatic Peptide Solution for Common Acute Gastrointestinal Bleeding Diseases: First Case Series Study on the Treatment Results of Endoscopic Hemostasis by Nonexpert Endoscopists.

INTRODUCTION: We investigated the hemostatic effect and safety of a hemostatic peptide solution for the treatment of gastrointestinal bleeding requiring emergency endoscopy. METHODS: We retrospectively examined the patient backgrounds, hemostatic results, and procedural safety in patients who were treated with a hemostatic peptide solution for hemostasis during emergency endoscopies for gastrointestinal bleeding. All hemostatic procedures were performed by nonexpert physicians with less than 10 years of endoscopic experience. All of the cases were treated at a single institution over the months from January 2022 to January 2023. RESULTS: Twenty-six consecutive patients (17 males and 9 females) with a median age of 74 (45-95) years were included. Their conditions requiring emergency endoscopy were melena in 8 patients, hematochezia in 2, hematemesis in 8, anemia in 6, and bleeding during esophagogastroduodenoscopy in 2. The sites of bleeding were the esophagus in 3 patients, the stomach in 17, the duodenum in 3, the small intestine in 2, and the colon in 1. Hemostasis was obtained with another hemostasis device used in conjunction with the hemostatic peptide solution in 13 cases and with the hemostatic peptide solution alone in 13 cases. The hemostasis success rate was 100%, with no complications. Rebleeding occurred within 1 week in 4 cases. CONCLUSION: Hemostasis with the hemostatic peptide solution was safe and provided a temporary high hemostatic effect in emergency gastrointestinal endoscopy.

Triggers of Ventricular Fibrillation in Patients With Inferolateral J-Wave Syndrome.

BACKGROUND: There are few data on ventricular fibrillation (VF) initiation in patients with inferolateral J waves. OBJECTIVES: This multicenter study investigated the characteristics of triggers initiating spontaneous VF in inferolateral J-wave syndrome. METHODS: A total of 31 patients (age 37 ± 14 years, 24 male) with spontaneous VF episodes associated with inferolateral J waves were evaluated to determine the origin and characteristics of triggers. The J-wave pattern was recorded in inferior leads in 11 patients, lateral leads in 3, and inferolateral leads in 17. RESULTS: The VF triggers (n = 37) exhibited varying QRS durations (176 ± 21 milliseconds, range 119-219 milliseconds) and coupling intervals (339 ± 46 milliseconds, range 250-508 milliseconds) with a right (70%) or left (30%) bundle branch block (BBB) pattern. Trigger patterns were associated with J-wave location: left BBB triggers with inferior J waves and right BBB triggers with lateral J waves. Electrophysiologic study was performed for 22 VF triggers in 19 patients. They originated from the left or right Purkinje system in 6 and from the ventricular myocardium in 10 and were undetermined in 6. Purkinje vs myocardial triggers showed distinct electrocardiographic characteristics in coupling interval and QRS-complex duration and morphology. Abnormal epicardial substrate associated with fragmented electrograms was identified in 9 patients, with triggers originating from the same region in 7 patients. Catheter ablation resulted in VF suppression in 15 patients (79%). CONCLUSIONS: VF initiation in inferolateral J-wave syndrome is associated with significant individual heterogeneity in trigger characteristics. Myocardial triggers have electrocardiographic features distinct from Purkinje triggers, and their origin often colocalizes with an abnormal epicardial substrate.

Comparison of Short-term Visual Acuity Changes After Trabeculotomy ab Interno Using Trabectome and Trabeculectomy ab Externo.

PURPOSE: To compare short-term visual acuity (VA) changes after trabeculotomy ab interno (TAI) using trabectome and trabeculectomy ab externo (TAE) performed on pseudophakic eyes. DESIGN: A single-center retrospective study. PARTICIPANTS: Patients with pseudophakic eyes who had primary open-angle glaucoma or exfoliation glaucoma and underwent TAI or TAE alone. METHODS: Changes in intraocular pressure (IOP), medication score, Snellen VA, and the number of eyes with vision loss (loss of ≥ 2 Snellen lines) were evaluated at baseline, week 1, and months 1, 3, and 6. The risk factors for vision loss at 6 months postoperatively were analyzed in both groups. MAIN OUTCOME MEASURES: Visual acuity changes. RESULTS: A total of 112 eyes of 112 patients were examined: 46 in the TAI group and 66 in the TAE group. Intraocular pressure was significantly lower in both groups at each visit than at baseline. The TAI group had a significantly higher mean postoperative IOP than the TAE group. Medication scores in the TAI group were significantly different after 3 months compared with baseline; however, decreased significantly at all study visits in the TAE group. The mean VA in the TAI group did not decrease significantly at each visit. In the TAE group, it decreased significantly up to 3 months but was not significantly different at 6 months. At all study visits, the number of eyes with vision loss was significantly lower in the TAI group than in the TAE group. Only 2 eyes in the TAI group (4.3%) had vision loss at 6 months, which was caused by macular edema. In the TAE group, 13 eyes (19.7%) experienced vision loss at 6 months. In all cases, the presence of preoperative split fixation [odds ratio = 7.30, P < 0.05] and the occurrence of hypotony-related complications [odds ratio = 6.76, P < 0.05] within 6 months were risk factors for vision loss. CONCLUSIONS: TAI lowered IOP less than TAE; however, there was less vision loss with TAI. For eyes with a target IOP in the mid-teens, TAI can be recommended as initial surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosuremay be found in the Footnotes and Disclosures at the end of this article.

Early postoperative visual acuity changes after trabeculectomy and factors affecting visual acuity.

PURPOSE: To investigate the early visual acuity (VA) changes that occur after trabeculectomy and their reversal with recovery. METHOD: Two hundred ninety-two eyes of 292 patients after initial trabeculectomy as a standalone procedure fulfilling the following conditions were included: 1) patients with a postoperative follow-up of at least 3 months; 2) patients with preoperative corrected VA less than 0.5 logMAR equivalent; 3) patients with reliable results of visual field; and 4) patients who had open angle glaucoma. VA and intraocular pressure (IOP) changes during the first 3 months after surgery and factors affecting VA postoperatively at 3 months were investigated. RESULTS: The mean IOPs (mmHg) after trabeculectomy were significantly lower than preoperatively during the entire period (P < 0.0001). The mean corrected VA for all patients was 0.06 ± 0.17, 0.24 ± 0.38, 0.19 ± 0.26, and 0.14 ± 0.27 preoperatively and at 1 week, 1 month, and 3 months postoperatively, respectively, showing a significant decrease from the preoperative period at all time points (P < 0.0001). VA loss of two or more levels was observed in 13 eyes (4.45%) at 3 months postoperatively. Foveal threshold (FT), shallow anterior chamber (SAC), and choroidal detachment (CD) affected the change in VA before and at 3 months after surgery (P < 0.0001, P = 0.0002, P = 0.0004, respectively). The factors that had significant effects on VA change were FT, SAC, and CD in POAG, FT and hypotonic maculopathy in NTG, and FT in XFG (p < 0.05). CONCLUSION: The frequency of serious vision loss was 4.45% for two or more levels of vision loss, and early postoperative VA changes after trabeculectomy may not be reversed even 3 months later. VA loss is influenced by preoperative FT, postoperative SAC and CD, but the impact of postoperative complications vary with disease type.

[Long-term Relapse-free Survival after Gefitinib Treatment Followed by Salvage Surgery for Postoperative Recurrence of Non-small Cell Lung Cancer:Report of a Case].

We present a case of a 54-year-old woman who had been performed video-assisted thoracic surgery (VATS) right upper lobectomy for stageⅡB adenocarcinoma. The patient had the recurrence of multiple lung metastases at 12 months after the surgery and was administrated gefitinib. The lung metastases disappeared at 3 months after the administration of gefitinib. A single metastasis in the left lower lung appearance again and VATS wedge left lung resection as salvage surgery was performed in postoperative 82 months. After salvage surgery, the patient has been followed up without additional treatment and is alive recurrence-free at 19 months.

[Reoperation for Recurrent Pulmonary Metastases].

From 1990 to 2019, 256 patients underwent surgery for metastatic lung tumors in our hospital, of which 23 (9.0%) had multiple surgeries. There were 15 cases of colorectal cancer, 2 cases of renal cancer, 2 cases of breast cancer, and 4 cases of others according to the primary lesion, and the number of operations was 2 times 18 cases, 3 times 4 cases, and 4 times 1 case. The average disease-free interval( DFI) was 27.2 months, and the average interval between the first and second operations was 25 months. The median observation period from the last surgery was 58.5 months, the 5-year survival rate was 67%, and the 10-year survival rate was 39%. If the surgical indication for metastatic lung tumor is satisfied and the prognostic factors such as long DFI or a small number of recurrences are met, re-surgery should be actively considered, and the significance of lung metastasectomy remains even now that drug therapy has advanced.

Back somersault-induced atrioventricular nodal reentrant tachycardia - A case of a 15-year-old promising gymnast.

A male 15-year-old promising gymnast suffered palpitations, which emerged only after landing a round-off back somersault. The performance induced an attack of regular narrow QRS complex tachycardia that was highly reproducible. Not a single element of the performance, but a whole sequence of round-off back somersault was required to induce the attack. An electrophysiologic study revealed an intra-nodal dual pathway causing atrioventricular nodal reentrant tachycardia (AVNRT). A complication of a tiny atrial septal defect (ASD) was incidentally detected, thus we initially suspected a causal relation of ASD as the platypnea-orthodeoxia syndrome. However, it was denied as the major mechanism of attack because of a very faint shunt flow and no-induction of hypoxemia during a round-off back somersault. The major triggering mechanisms of a whole sequence of round-off back somersaults were speculated to be related to transient atrial overload and autonomic imbalance induced by a swift postural-axial change together with an intense Valsalva maneuver with the maximal level of breath holding. The AVNRT attack was successfully treated by radiofrequency catheter ablation and has never recurred even by a whole sequence of round-off back somersaults. Currently he is a healthy and active gymnast with no symptoms. .

Blood-Brain Barrier Crossing Renin-Angiotensin Drugs and Cognition in the Elderly: A Meta-Analysis.

[Figure: see text].

Simultaneous separation of 17 anions by capillary electrophoresis with the addition of an organic solvent.

Seventeen inorganic and organic anions, that normally are insufficiently separated via ion chromatography, were completely separated by the addition of an organic solvent to a solution of BGE combined with an adjustment of the apparent pH via CE in combination with indirect UV absorbance detection. Methanol, ethanol, and acetonitrile were examined for their utility in manipulating the selective separation of anions. Methanol and acetonitrile were better modifiers than ethanol at enhancing the resolution of anions comigrating in an aqueous solution of BGE. Methanol was selected as the modifier that provided the largest separation window that could achieve a complete separation of the target analytes. Via the use of methanol, manipulation of the selectivity between inorganic anions and that between inorganic and organic anions was enhanced, but the separation between organic anions remained difficult when only methanol was used. By varying the apparent pH of the BGE in the presence of 10% v/v methanol, however, the separation selectivity between organic anions was substantially improved. Eventually, 7 inorganic and 10 organic anions were simultaneously separated using BGE at a pH of 6.3 in the presence of 10% v/v methanol.

Clinical significance of bifocal treatment for synchronous brain metastasis in T1-2 non-small-cell lung cancers: JNETS0301.

OBJECTIVES: The treatment of patients with brain metastases associated with non-small-cell lung cancer (NSCLC) is frequently challenging. Starting in 2003, we conducted a phase II study of surgery for patients with clinical T1-2N0-1 NSCLC with oligometastasis. The aim of this subset study was to assess the clinical significance of bifocal treatment for synchronous brain metastases in T1-2N0-1 NSCLC using prospectively collected data. METHODS: In this phase II study of clinical T1-2N0-1 NSCLC patients with oligometastasis, 47 patients were enrolled from December 2003 to December 2016. Among them, 18 NSCLC patients with synchronous brain metastases were investigated in this subset analysis. RESULTS: Fourteen patients underwent complete resection, and 4 underwent incomplete resection of the primary lung cancer. The number of synchronous brain metastases was one in 14 and multiple in 4 patients. After surgery for the primary lung cancer, 12 of 18 patients underwent treatment for their brain lesions, including stereotactic radiosurgery (SRS) in 10, surgical resection in 1, and SRS followed by surgical resection in 1. In 5 of the 18 patients (28%), the brain lesion was diagnosed as benign on follow-up radiological imaging. The 5-year overall survival rate after enrollment was 31.8% for all 18 patients and 35.2% for the 13 patients with brain metastases. Univariate analysis showed that having multiple brain lesions was a significant factor related to a worse prognosis. CONCLUSION: For patients with suspected brain metastases associated with NSCLC, bifocal local treatment could be an acceptable therapeutic strategy, especially for solitary brain metastasis.

Acute Myocardial Infarction in a 17-year-old High-school Girl.

We report an unusual case of acute myocardial infarction in a high school girl. The patient was 17 years of age and had multiple coronary risk factors, including marked obesity with a body mass index (BMI) of 42.7 kg/m2, dyslipidemia and glucose intolerance. She had been an on and off smoker since she was 13 years of age. Due to the recent Westernization of the lifestyle, the prevalence of metabolic syndrome in the young generation has been increasing in Japan. Cardiovascular disease based on lifestyle-related diseases may become more common in young people.

Comparison between unattended automated office blood pressure and conventional office blood pressure under the environment of health checkup among Japanese general population.

Unattended automated office blood pressure (AOBP) measurement has been endorsed as the preferred in-office measurement modality in recent Canadian and American clinical practice guidelines. However, the difference between AOBP and conventional office blood pressure (CBP) under the environment of a health checkup remains unclear. We aimed to identify the clinical significance of AOBP as compared to CBP under the environment of a health checkup. There were 491 participants (333 females, mean age of 62.5 years) who were at least 20 years old, including 179 participants who were previously diagnosed with hypertension. Mean AOBPs were 131.8 ± 20.9/76.6 ± 11.7 mm Hg, and CBPs were 135.6 ± 21.6/77.3 ± 11.5 mm Hg. There was a difference of 3.9 mm Hg in systolic blood pressure (SBP) and 0.8 mm Hg in diastolic BP between AOBP and CBP. In all participants, SBP and pulse pressure, as well as the white coat effect (WCE), increased with age. The cutoff value used was 140/90 mm Hg for CBP and 135/85 mm Hg for AOBP, and the prevalence of WCE and masked hypertension effect (MHE) was 12.4% and 14.1%, respectively. Even in a health checkup environment of the general population, there was a difference between the AOBP and CBP, and the WCE was observed more strongly in the elderly with a history of hypertension, suggesting that a combination of AOBP with CBP may be useful in detecting WCE and MHE in all clinical scenarios including health checkups, and help solve the "hypertension paradox" not only in Japan but in all over the world.

A phase 2 study of adjuvant carboplatin plus S-1 followed by maintenance S-1 therapy for patients with completely resected stage II/IIIA non-small cell lung cancer-Japanese Northern East Area Thoracic Surgery Study Group JNETS1302 study.

BACKGROUND: The standard adjuvant chemotherapy regimen for completely resected pathological stage II/IIIA non-small cell lung cancer (NSCLC) is four courses of cisplatin plus vinorelbine. However, the continuity and toxicity of cisplatin-based regimens remain problematic. Conversely, carboplatin-based chemotherapy is a less toxic and more tolerable regimen for various stages of NSCLC. In particular, the efficacy and tolerability of carboplatin plus S-1 in advanced NSCLC were confirmed by previous pivotal studies such as the LETS trail. Therefore, this phase II study assessed the feasibility, safety, and usefulness of carboplatin plus S-1 followed by maintenance S-1 as an adjuvant treatment. METHODS: In this single-arm, multicenter phase II study, 40 patients who previously underwent complete resection of NSCLC were enrolled from November 2013 to January 2015. The chemotherapy protocol was four cycles of carboplatin (AUC 5 on day 1) and oral S-1 (80 mg/m2 every other day from days 1 to 21) followed by oral S-1 (80 mg/m2 every other day for 48 weeks). The primary endpoint was the treatment completion rate, and the secondary endpoints were adverse events and 2-year recurrence-free survival. RESULTS: The treatment completion rate of the planned schedule was as low as 30.0% (90% confidence interval: 40.3-63.0%). The reasons for adjuvant chemotherapy discontinuation were adverse events, refusal, tumor recurrence, and other reasons in 13, 6, 10, and 2 patients, respectively. The 2-year progression-free survival rate was 66.7% among patients who completed maintenance chemotherapy. There were no treatment-related deaths, and most adverse events were less than grade 3. CONCLUSIONS: Carboplatin plus S-1 followed by S-1 maintenance for 1 year in the adjuvant treatment of NSCLC was not tolerable, although most adverse events were not severe. However, patients who can fully complete the regimen might experience clinical benefit.

Assessment of suitable antihypertensive therapies: Combination with high-dose amlodipine/irbesartan vs triple combination with amlodipine/irbesartan/indapamide (ASAHI-AI study).

Angiotensin receptor blockers (ARBs) plus calcium channel blockers (CCBs) are a widely used combination therapy for hypertensive patients. In order to determine which combination was better as the next-step therapy for standard-dose combination of ARBs and CCBs, a combination with high-dose CCBs or a triple combination with diuretics, the authors conducted a prospective, randomized, open-label trial to determine which of the following combination is better as the next-step treatment: a combination with high-dose CCBs or a triple combination with diuretics. Hypertensive outpatients who did not achieve their target blood pressure (BP) with usual dosages of ARBs and amlodipine 5 mg were randomly assigned to treatment with irbesartan 100 mg/amlodipine 10 mg (Group 1: n = 48) or indapamide 1 mg in addition to ARBs plus amlodipine 5 mg (Group 2: n = 46). The primary end point was changes in the systolic BP (SBP) and diastolic BP (DBP) after the 12-week treatment period, while secondary end points were changes in BP after the 24-week treatment period and laboratory values. At 12 weeks, the SBP/DBP significantly decreased from 152.1/83.4 mm Hg to 131.5/76.1 mm Hg in Group 1 and 153.9/82.1 mm Hg to 132.7/75.9 mm Hg in Group 2. Although both groups produced a similar efficacy in reducing the SBP/DBP (-19.2/-9.2 mm Hg in Group 1 and -21.6/-8.8 mm Hg in Group 2; SBP P = .378, DBP P = .825), high-dose CCBs combined with ARBs controlled hypertension without elevation of serum uric acid. These results will provide new evidence for selecting optimal combination therapies for uncontrolled hypertensive patients.

[Iatrogenic Injury of the Bronchus Suspiciously Caused by Sengstaken-Blakemore Tube into the Airway].

BACKGROUND: Tracheobronchial injury is often operated urgently because of the risk of high mortality. However, small injuries can recover by conservative management. CASE: A 65-year-old man was treated for esophageal varix with transcatheter arterial embolization therapy. He vomited blood and endoscopic sclerotherapy was performed because a Sengstaken-Blake-more tube could not be inserted. Thereafter, computed tomography( CT) detected mediastinal emphysema and an injury to his left main bronchus. The patient consulted our department and bronchoscopy detected a laceration of the left main bronchus. Conservative management was chosen because the laceration was limited to the membranous portion, with the improvement of inflammatory reaction. Several weeks later, CT and bronchoscopy confirmed recovery from the injury of the left main bronchus without stricture. CONCLUSION: An operation is indicated for many tracheobronchial injuries. However, some injuries can recover with conservative management. It is important that indication for surgery should be considered based on bronchoscopic findings and the progress of inflammatory reaction.

A case of massive hemothorax associated with an intrathoracic bronchogenic cyst.

A 34-year-old man presented with sudden back pain and dyspnea. Chest X-ray showed left-sided massive pleural effusion. Chest computed tomography revealed an intrathoracic mass sized 9 cm. Hemorrhagic effusion was achieved with thoracic drainage on admission. Diagnostic video-assisted surgery was indicated, and an unexpected cyst with bloody content was observed. The cyst was bluntly dissected from the pleura and removed from the diaphragm. The patient discharged uneventfully and there were no significant postoperative complications including bleeding or pneumothorax. Pathological observation of the cyst revealed pseudostratified ciliated epithelial cells, mucinous glands, and cartilage compatible with the diagnostic criteria for a bronchogenic cyst. Malignant transformation was not observed. Common clinical presentations of bronchogenic cysts include pain, dyspnea, and cough. Although rare, the risk of hemorrhage from bronchogenic cysts and subsequent development of hemothorax should not be underestimated.

[A Pulmonary Mucoepidermoid Carcinoma with Anaplastic Lymphoma Kinase Fusion Responding to Alectinib Hydrochloride].

Few cases of lung mucoepidermoid carcinomas with anaplastic lymphoma kinase (ALK) fusion have been reported. A 35-year-old woman was found to have an abnormal chest X-ray. A tumor and obstructive pneumonitis in her left upper lobe was detected using computed tomography (CT). She was admitted to our hospital, and was diagnosed with mucoepidermoid carcinoma by transbronchial biopsy. Left pneumonectomy and lymphadenectomy were performed for lung mucoepidermoid carcinoma and a mediastinal lymph node metastasis (pT2aN2M0, stage ⅢA). Postoperative radiotherapy (50 Gy) to the mediastinum and chemotherapy were performed followed by several radiotherapies for cervical and mediastinal lymph node and right ischium metastases. Since then, further radiotherapy was impossible. However, we detected ALK fusion in the resected specimen and the cancer responded to alectinib hydrochloride.