[Small intestinal mucormycosis associated with acute myeloid leukemia: a case report].

The patient was a man in his 70s. During the treatment for acute myeloid leukemia, abdominal pain and bloody stools appeared. A diagnosis of small intestinal ileus was made by computed tomography scan. Treatment with an ileus tube did not improve his condition, and enteroscopy revealed the presence of ileal ulcers. Based on histological examination, small intestinal mucormycosis was suspected, and thus, antifungal drugs were administered. However, the patient developed perforated peritonitis and underwent small intestine resection. He was finally diagnosed with small intestinal mucormycosis with the help of the resected specimen. The gastrointestinal form of mucormycosis rarely occurs, and small intestinal lesions are very rare. Enteroscopy was helpful in its diagnosis and treatment.

Retroperitoneoscopic resection of a primary retroperitoneal paraganglioma occurring between the aorta and vena cava: A case report.

A 67-year-old man presented with lower limb weakness, palpitations, and insomnia. His urinary total metanephrine and normetanephrine levels were high. Computed tomography showed a 48 × 34-mm oval mass on the dorsal side of the pancreas and portal vein between the aorta and vena cava. Because of the tumor location, we performed laparoscopic surgery using a retroperitoneal approach. We described a case of a patient with primary retroperitoneal paraganglioma between the aorta and vena cava who underwent retroperitoneoscopic resection. Our case suggests that this procedure can be safely performed.

A case of robot-assisted adrenalectomy performed for an adrenal tumor (anastomosing hemangioma) exceeding 7 cm.

Introduction: Anastomosing hemangioma in the adrenal area is extremely rare. We report a large anastomosing hemangioma in the adrenal area that underwent robot-assisted adrenalectomy. Case presentation: A 49-year-old man with left back pain underwent magnetic resonance imaging (MRI) that revealed a tumor in the left adrenal area; it was diagnosed as nonfunctional endocrinologically. However, the major axis of the tumor increased from 64 to 72 mm during the 4-month period. Robot-assisted left adrenalectomy was performed. Although the large tumor adhered to the surrounding tissues, it was safely resected by the effective use of an extra robotic arm. An anastomosing hemangioma was diagnosed since there were no malignant findings. Conclusion: Robotic surgical systems may serve as an effective treatment option for large adrenal tumors, and our report is the first robot-assisted adrenalectomy performed on an anastomosing hemangioma.

Two cases of pelvic schwannomas simultaneously resected with the prostate by robot-assisted surgery.

INTRODUCTION: Schwannoma is a rare benign tumor of peripheral nerves arising from Schwann cells of the ubiquitous nerve sheath. The operative steps and technical aspects of robotic resection of pelvic schwannoma are described herein. CASE PRESENTATION: We describe two patients with pelvic tumors simultaneously resected with the prostate by robot-assisted surgery: a 69-year-old man with schwannoma of the right side of the pelvic floor and a 68-year-old man with schwannoma in the left pelvis. As metastasis of prostate cancer could not be ruled out, tumorectomy was performed using robotic-associated prostatectomy. Malignancy was absent in the two pelvic tumors, and the patients were diagnosed with schwannoma. CONCLUSION: For surgery in a narrow deep pelvis, robot-assisted surgery is minimally invasive, offers excellent mobility of robotic instruments and visibility of three-dimensional view, and is a useful approach.

Reversible Redox Property of Co(III) in Amorphous Co-doped SiO2/γ-Al2O3 Layered Composites.

This paper reports on a unique reversible reducing and oxidizing (redox) property of Co(III) in Co-doped amorphous SiO2/γ-Al2O3 composites. The Fenton reaction during the H2O2-catalyzed sol-gel synthesis utilized in this study lead to the partial formation of Co(III) in addition to Co(II) within the composites. High-resolution transmission electron microscopy (HRTEM) and high-angle annular dark-field scanning transmission electron microscopy (HAADF-STEM) analyses for the composite powder sample with a composition of Al:Si:Co = 85:10:5 showed the amorphous state of the Co-doped SiO2 that modified γ-Al2O3 nanocrystalline surfaces. In situ X-ray absorption fine structure (XAFS) spectroscopic analysis suggested reversible redox reactions of Co species in the composite powder sample during heat-treatment under H2 at 500 °C followed by subsequent cooling to RT under Ar. Further analyses by in situ IR spectroscopy combined with cyclic temperature programmed reduction/desorption (TPR/TPD) measurements and X-ray photoelectron spectroscopic (XPS) analysis revealed that the alternating Co(III)/(II) redox reactions were associated with OH formation (hydrogenation)-deformation (dehydrogenation) of the amorphous aluminosilicate matrix formed in situ at the SiO2/γ-Al2O3 hetero interface, and the redox reactions were governed by the H2 partial pressure at 250-500 °C. As a result, a supported mesoporous γ-Al2O3/Co-doped amorphous SiO2/mesoporous γ-Al2O3 three-layered composite membrane exhibited an H2-triggered chemical valve property: mesopores under H2 flow (open) and micropores under He flow (closure) at 300-500 °C.

Management of biliary stricture in patients with IgG4-related sclerosing cholangitis.

BACKGROUND: We aimed to determine the optimal approach with endoscopic biliary drainage (EBD) and corticosteroid (CS) for the treatment of IgG4-related sclerosing cholangitis (ISC). METHODS: To evaluate the safety of EBD for treatment of biliary stricture caused by ISC, we assessed the risk of stent dislodgement and sought to determine the most appropriate time for stent removal. We also assessed the safety of treatment with CS alone for patients with obstructive jaundice, and the rate of and risk factors for biliary tract complications. RESULTS: Sixty-nine patients with ISC treated with CS were enrolled. Twenty-eight patients (40.6%) were treated with EBD for biliary stricture before CS initiation. Intentional stent removal was performed in thirteen (46.4%) after confirming CS-induced improvement. Eleven of thirteen patients (84.6%) underwent stent removal within 1 month after CS initiation and all their stent removals were safely carried out without early (within two weeks) recurrence of obstructive jaundice. Ten of twenty-eight patients (35.7%) experienced spontaneous stent dislodgement after CS initiation, and seven (70%) of them developed stent dislodgement two weeks to two months after CS initiation. Among forty-one patients treated with CS alone without EBD, 10 patients had obstructive jaundice at the time of CS initiation and all of them achieved clinical improvement without biliary tract infection. During the follow-up, three patients (4.3%), all of whom had undergone EBD, developed bile-duct stones, while none of those treated with CS alone developed bile-duct stones (p = 0.032). Long-term biliary stenting was a risk factor for bile-duct stones. CONCLUSIONS: Biliary stent removal should be carried out within 2 weeks after CS initiation if biliary stricture improves to prevent stent dislodgement. Obstructive jaundice can be treated safely with CS alone in patients without infection. Clinicians should be aware of the possibility of bile-duct stones in patients treated with EBD.

Efficacy of Vonoprazan for 48-Week Maintenance Therapy of Patients with Healed Reflux Esophagitis.

AIMS: We aimed to evaluate the efficacy of vonoprazan (VPZ) as maintenance therapy for healed reflux esophagitis (RE). METHODS: We enrolled 74 patients diagnosed with RE with frequency scale for the symptoms of gastroesophageal reflux disease (FSSG) total score ≥8 after at least 8 weeks of treatment with standard proton pump inhibitors (PPIs). These patients were switched to VPZ 20 mg for 4 weeks. We also enrolled 71 patients with no endoscopic evidence of erosive esophagitis who received maintenance therapy with VPZ 10 mg for 48 weeks. The primary end point was the proportion of patients who maintained healed RE refractory to PPIs after 48 weeks of maintenance therapy with on demand 10 mg VPZ. Secondary assessment included the proportion of patients with symptomatic nonrelapse at 48 weeks. RESULTS: Fifty patients successfully completed 48-week maintenance therapy. Maintenance therapy with VPZ 10 mg prevented the relapse of esophageal mucosal breaks in 43 (86.0%) of 50 patients at 48 weeks. During the 48-week maintenance therapy, symptomatic nonrelapse rate for acid reflux-related symptom score of FSSG and acid reflux score of Gastrointestinal Symptom Rating Scale at 48 weeks were 70.0 and 72.0%, respectively. No serious adverse events were reported during the study. CONCLUSION: VPZ 10 mg is clinically effective for maintenance of healed RE for 48 weeks.

Efficacy of vonoprazan for 24-week maintenance therapy of patients with healed reflux esophagitis refractory to proton pump inhibitors.

The aim of the present study was to evaluate the efficacy of a potassium-competitive acid blocker (P-CAB), vonoprazan, for the maintenance therapy of healed reflux esophagitis (RE). A total of 60 patients were enrolled in this open-label, single-center, prospective study. All patients were diagnosed with RE with a frequency scale for the symptoms of gastroesophageal reflux disease (FSSG) total score ≥8 following treatment with standard proton pump inhibitors (PPIs) for a minimum of 8 weeks. Standard PPI treatment was switched to vonoprazan 20 mg once daily for 4 weeks. A total of 52 patients, who had no endoscopic evidence of erosive esophagitis following vonoprazan treatment, received maintenance therapy with vonoprazan 10 mg once daily for 24 weeks. Symptoms were evaluated using the FSSG and Gastrointestinal Symptom Rating Scale (GSRS). Upper gastrointestinal endoscopies were performed following 24 weeks of maintenance therapy. The primary endpoint was to determine the proportion of patients who exhibited maintenance of healed RE refractory to PPIs following 24 weeks of maintenance therapy with vonoprazan 10 mg once daily. Secondary endpoints included evaluation of the proportion of patients with symptomatic non-relapse at 24 weeks. Maintenance therapy with vonoprazan 10 mg once daily prevented relapse of esophageal mucosal breaks in 37/43 (86.0%) patients at 24 weeks. However, the number of patients with symptomatic relapse was 1 (1.9%) and 4 (7.7%) at 4 and 8 weeks, respectively. A total of 4 patients were withdrawn due to loss to follow-up. At the end of the 24-week maintenance period, the symptomatic non-relapse rate for acid reflux-associated and dysmotility symptom FSSG scores were 86.5 and 80.8%, respectively. Furthermore, the symptomatic non-relapse rate for reflux, abdominal pain, indigestion, diarrhea, and constipation GSRS scores at 24 weeks were 86.5, 80.8, 75.0, 71.2 and 76.9%, respectively. No serious adverse events were reported during the study. The mean gastrin level was 1,059 pg/ml. In conclusion, the results of the present study indicate that vonoprazan 10 mg once daily is effective for 24-week maintenance therapy of healed RE refractory to PPIs.

Prognosis of type 1 autoimmune pancreatitis after corticosteroid therapy-induced remission in terms of relapse and diabetes mellitus.

BACKGROUND AND AIM: Relapse and diabetes mellitus (DM) are major problems for the prognosis of autoimmune pancreatitis (AIP). We examined the prognosis of type 1 AIP after corticosteroid therapy (CST)-induced remission in terms of relapse and DM. METHODS: The study enrolled 82 patients diagnosed with type 1 AIP who achieved remission with CST. We retrospectively evaluated the relapse rate in terms of the administration period of CST, clinical factors associated with relapse, and the temporal change in glucose tolerance. RESULTS: During follow-up, 32 patients (39.0%) experienced relapse. There was no significant clinical factor that could predict relapse before beginning CST. AIP patients who ceased CST within 2 or 3 years experienced significantly earlier relapse than those who had the continuance of CST (p = 0.050 or p = 0.020). Of the 37 DM patients, 15 patients (40.5%) had pre-existing DM, 17 (45.9%) showed new-onset DM, and 5 (13.5%) developed CST-induced DM. Patients with new-onset DM were significantly more likely to show improvement (p = 0.008) than those with pre-existing DM. CONCLUSIONS: It was difficult to predict relapse of AIP based on clinical parameters before beginning CST. Relapse was likely to occur within 3 years after the beginning of CST and maintenance of CST for at least 3 years reduced the risk of relapse. The early initiation of CST for AIP with impaired glucose tolerance is desirable because pre-existing DM is refractory to CST.

Recent effectiveness of proton pump inhibitors for severe reflux esophagitis: the first multicenter prospective study in Japan.

Proton pump inhibitors are the first-line treatment for reflux esophagitis. Because severe reflux esophagitis has very low prevalence in Japan, little is known about the effectiveness of proton pump inhibitors in these patients. This prospective multicenter study assessed the effectiveness of proton pump inhibitors for severe reflux esophagitis in Japan. Patients with modified Los Angeles grade C or D reflux esophagitis were treated with daily omeprazole (10 or 20 mg), lansoprazole (15 or 30 mg), or rabeprazole (10, 20, or 40 mg) for 8 weeks. Healing was assessed endoscopically, with questionnaires administered before and after treatment to measure the extent of reflux and dyspepsia symptoms. Factors affecting healing rates, including patient characteristics and endoscopic findings, were analyzed. Of the 115 patients enrolled, 64 with grade C and 19 with grade D reflux esophagitis completed the study. The healing rate was 67.5% (56/83), with 15 of the other 27 patients (55.6%) improving to grade A or B. No patient characteristic or endoscopic comorbidity was significantly associated with healing rate. Reflux and dyspepsia symptoms improved significantly with treatment. The low healing rate suggests the need of endoscopic examination to assess healing of reflux esophagitis at the end of therapy. (UMIN000005271).

[Successful treatment of enterohemorrhagic Escherichia coli O111-induced hemolytic-uremic syndrome and acute encephalopathy].

We report a case of a woman in her twenties with enterohemorrhagic Escherichia coli O111-induced hemolytic-uremic syndrome who developed acute encephalopathy on day 5 of admission. She recovered after treatment with steroid pulse therapy, plasmapheresis, and recombinant thrombomodulin, without any adverse sequelae. We report this interesting case and provide a summary of the recent outbreak of enterohemorrhagic Escherichia coli O111.

Core lower urinary tract symptom score questionnaire: a psychometric analysis.

OBJECTIVES: To analyze the reliability and validity of the Japanese version of the core lower urinary symptom score questionnaire with psychometric methods. METHOD: The present study included 140 women and 125 men who filled in a core lower urinary symptom score questionnaire while attending two lectures on lower urinary tract symptoms. Missing response rates to individual questions were 1.5-5.3%. After the descriptive analyses including box plot, Cronbach's α coefficients and Spearman's ρ were calculated for reliability and validity assessment, respectively. Factor analysis was also carried out to explore the underlying structure. RESULTS: Of the scores for 10 core symptoms, the interquartile range for pain in the bladder and urethra was 0 in both sexes, and that for stress incontinence was 0 in men. Cronbach's α of the core lower urinary symptom score was 0.733 in women and 0.721 in men. Questions regarding daytime frequency, nocturia, urgency and urgency urinary incontinence, and those on slow stream, straining and feeling of incomplete emptying were significantly correlated with each other in both sexes. Pain in the urethra and bladder showed more extensive associations in women than in men. Factor analysis showed four components in both sexes: the first was storage symptoms, second was voiding symptoms, third was pain and the fourth was urinary incontinence. CONCLUSIONS: The core lower urinary symptom score questionnaire shows good reliability and validity for both sexes, and it could be used as screening tool for lower urinary tract symptoms in any clinical setting or epidemiological investigation.

Potential role of transient receptor potential (TRP) channels in bladder cancer cells.

Transient receptor potential (TRP) channels play important roles in thermal, chemical, and mechanical sensation in various tissues. In this study, we investigated the differences in urothelial TRP channels between normal urothelial cells and bladder cancer cells. TRPV2 and TRPM7 expression levels and TRPV2 activator-induced intracellular Ca(2+) increases were significantly higher, whereas TRPV4 expression and TRPV4 activator-induced intracellular Ca(2+) increases were significantly lower in mouse bladder cancer (MBT-2) cells compared to normal mouse urothelial cells. The proliferation rate of MBT-2 cells overexpressing dominant-negative TRPV2 was significantly increased. In contrast, treatment with TRPV2 activators significantly decreased the proliferation rate. TRPM7-overexpressing MBT-2 cells proliferated more slowly, as compared to mock-transfected cells. Moreover, expression of dominant-negative TRPV2 significantly decreased plasma membrane Ca(2+) permeability of MBT-2 cells as compared to that in mock-transfected cells. Increases in the expression of TRPV2 mRNA, immunoreactivity, and TRPV2 activator-induced intracellular Ca(2+) were also observed in T24 human bladder cancer cells. These results suggested that TRPV2 and TRPM7 were functionally expressed in bladder cancer cells and served as negative regulators of bladder cancer cell proliferation, most likely to prevent excess mechanical stresses.

Retroperitoneoscopic drainage of bilateral psoas abscesses under intraoperative laparoscopic ultrasound guidance.

Despite improved diagnostic modalities for psoas abscesses, the optimum management strategy is not uniform. A 67-year-old man presented with bilateral psoas abscesses secondary to L1-L2 pyogenic discitis. On contrast-enhanced CT, the largest of these abscesses measured 13 × 14 × 33 mm on the right. The patient developed sepsis caused by Klebsiella pneumonia. There were no signs of improvement after 3 weeks of systematic antibiotic administration. We performed surgical drainage of bilateral psoas abscesses by retroperitoneoscopy. Intraoperative laparoscopic ultrasound was useful to determine abscess location in the muscles prior to drainage and confirm no residual abscesses after drainage. The patient was afebrile 3 days later, and his clinical symptoms resolved. Retroperitoneoscopic drainage may represent a feasible minimally invasive therapeutic option for psoas abscess, and intraoperative laparoscopic ultrasound has the potential to increase the safety and efficacy of this surgical procedure.

[A case of myelitis with anti-aquaporin 4 antibody concomitant with immune thrombocytopenic purpura].

We report a 44-year-old woman who had anti-aquaporin 4 (AQP4) antibody-positive myelitis and immune thrombocytopenic purpura (ITP). She was admitted to our hospital with paraparesis, dysesthesia below the Th8 dermatome level on her right side and lower extremities, constipation and urinary retention. Magnetic resonance imaging revealed a longitudinally extending lesion at the level of Th4-Th10. Her serum sample was positive for anti-AQP4 antibody. Corticosteroid therapy was initiated, and her symptoms were largely ameliorated. Furthermore, concurrently with the myelitis, her platelet count dropped (99 × 10(9)/l). A diagnosis of ITP was made with positive serum platelet-associated IgG (PA-IgG) and negative work-up for blood malignancies by bone marrow aspiration. Since a causal relationship between Helicobacter pylori (H. pylori) and ITP is suggested by several studies, she was also examined and diagnosed with H. pylori-positive ITP. After the bacteria eradication therapy, her platelet count and PA-IgG returned to normal range. Furthermore, the anti-AQP4 antibody titer declined and her symptoms were almost resolved. We considered that H. pylori might influence progression of the myelitis as well as induction and development of ITP.

Effect of tamsulosin on bladder microcirculation in rat model of bladder outlet obstruction using pencil lens charge-coupled device microscopy system.

OBJECTIVE: To determine the effect of tamsulosin hydrochloride on blood flow in the submucosal capillaries of the bladder (SCB) in a rat model of bladder outlet obstruction (BOO) using a pencil lens charge-coupled device microscopy system. MATERIALS AND METHODS: BOO was established in rats by partial ligature of the proximal urethra and was maintained for 2 weeks. Tamsulosin or saline (control) was subcutaneously administered using an osmotic pump for 2 weeks immediately after surgery. The pencil lens charge-coupled device microscopy system was used to visualize the bladder microcirculation and quantitatively assess the blood flow in the SCB by measuring the velocity of the blood flow at the base and dome of the bladder. The blood flow in the SCB of the sham-operated rats, control BOO rats, and tamsulosin-treated BOO rats was compared. RESULTS: The blood flow in the SCB was significantly greater at the base than at the dome of the bladder. The reduction in blood flow through the SCB at the base and dome of the bladder was more significant in the BOO rats than in the sham-operated rats. However, after pretreatment with tamsulosin, the BOO rats showed a significant increase in blood flow through the SCB at the base and dome of the bladder compared with that of the control rats. The pencil lens charge-coupled device microscopy system image showed that the BOO rats had chronic ischemic capillary injury, which was ameliorated by tamsulosin. CONCLUSION: The results of the present study suggest that tamsulosin hydrochloride protects the SCB from ischemic injury after BOO.

FUS/TLS-immunoreactive neuronal and glial cell inclusions increase with disease duration in familial amyotrophic lateral sclerosis with an R521C FUS/TLS mutation.

Basophilic inclusions (BIs) are pathological features of a subset of frontotemporal lobar degeneration disorders, including sporadic amyotrophic lateral sclerosis (ALS) and familial ALS (FALS). Mutations in the fused in sarcoma/translocated in liposarcoma (FUS/TLS) gene have recently been identified as a cause of FALS. The FUS/TLS-immunoreactive inclusions are consistently found in cases of frontotemporal lobar degeneration with BIs; however, the association between ALS cases with BIs and FUS/TLS accumulation is not well understood. We used immunohistochemistry to analyze 3 autopsy cases of FALS with the FUS/TLS mutation and with BIs using anti-FUS/TLS antibodies. The disease durations were 1, 3, and 9 years. As the disease duration becomes longer, there were broader distributions of neuronal and glial FUS/TLS-immunoreactive inclusions. As early as 1 year after the onset, BIs, neuronal cytoplasmic inclusions and glial cytoplasmic inclusions were found in the substantia nigra in addition to the anterior horn of the spinal cord. Glial cytoplasmic inclusions are found earlier and in a wider distribution than neuronal cytoplasmic inclusions. The distribution of FUS/TLS-immunoreactive inclusions in FUS/TLS-mutated FALS with BIs was broader than that of BIs alone, suggesting that the pathogenetic mechanism may have originated from the FUS/TLS proteinopathy.