[A case of autopsy-confirmed duodenal perforation due to calcium polystyrene sulfonate].

A 77-year-old male patient was referred to our hospital because of jaundice. He was diagnosed with alcoholic liver cirrhosis and was admitted to our hospital because of liver failure. After admission, we observed conservative liver disease, but the liver damage did not improve and gradually worsened. Renal function deteriorated during liver failure. Hyperkalemia presented due to renal dysfunction. Hence, calcium polystyrene sulfonate (CPS) was initiated. He died because of liver failure although hyperkalemia improved. An autopsy revealed ulcer perforation with CPS crystals in the duodenum. A basic substance considered a crystal of CPS was found by hematoxylin and eosin staining from the ulcer adjacent to the perforation and the exudate attached to the peritoneum. Furthermore, a large amount of CPS crystals were found in the ascites. A final diagnosis of gastrointestinal perforation peritonitis due to CPS was made. Gastrointestinal perforation due to CPS is presumed as a direct mucosal injury due to the drug, most of which is the sigmoid colon of elderly patients. Upper gastrointestinal tract perforation is extremely rare. We experienced a case of autopsy in which duodenal perforation due to CPS was pathologically confirmed. CPS is a widely used drug for renal disorders, but it has a risk of gastrointestinal injury. Therefore, a potential gastrointestinal mucosal injury should be considered when using CPS.

Magnifying Narrow-Band Imaging with Acetic Acid Spray for Superficial Non-Ampullary Duodenal Epithelial Tumors Based on the Mucin Phenotype.

INTRODUCTION: This study aimed to identify the characteristics of superficial non-ampullary duodenal epithelial tumors (SNADETs) based on the mucin phenotype using magnifying narrow-band imaging with acetic acid spray (MA-NBI) and evaluate the efficacy of MA-NBI in differentiating gastric-type (G-type) from intestinal-type (I-type) lesions. METHODS: We retrospectively identified 59 resected SNADETs in 59 patients who underwent MA-NBI. We evaluated surface patterns using MA-NBI to differentiate G-type from I-type lesions. Surface structures were classified into three patterns: tubular, villous, or oval structures. Lesions displaying a single pattern among the three patterns were classified as monotype, whereas those displaying multiple surface patterns were classified as mixed type. In addition, lesions with disorganized and unclear structures with irregular margins were classified as irregular surface structures. RESULTS: In total, 32 (54%), 26 (44%), and 1 (2%) lesions were classified as Vienna category 3, 4, and 5 tumors, respectively, whereas 49 (83%) and 10 (17%) were classified as I- and G-type lesions, respectively. Oval structures were more frequently observed in G-type lesions (70%), whereas tubular structures were more frequently observed in I-type lesions (78%) (p < 0.001). Category 4 and 5 lesions had significantly higher mixed and irregular surface structure rates than category 3 lesions (41 vs. 6%, p = 0.003 and 81 vs. 3%, p < 0.001, respectively). CONCLUSION: MA-NBI can distinguish the mucin phenotypes of SNADETs and may facilitate histological grade diagnosis.

Late recurrence of early gastric cancer 11 years after curative endoscopic submucosal dissection.

A 73-year-old man was initially diagnosed with a 50-mm, depressed-type early gastric cancer on the anterior wall of the angulus, and the lesion was curatively resected en bloc by endoscopic submucosal dissection. Pathology revealed a 54 mm × 43 mm differentiated-type predominant adenocarcinoma with focal undifferentiated-type component that was confined to the mucosa without ulceration. Eleven years after endoscopic submucosal dissection, lymph node metastasis along the lesser curve was incidentally detected on magnetic resonance imaging and diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy. The patient received distal gastrectomy with D2 lymph node dissection. A resected lymph node revealed a well-differentiated adenocarcinoma with a poorly differentiated component; thus, the final diagnosis was late recurrence of early gastric cancer originally treated by endoscopic submucosal dissection. This report demonstrates that metastatic recurrence may occur in curative endoscopic submucosal dissection for early gastric cancer and that gastric cancer can recur even after more than 5 years.

Effects of ultrasound irradiation on Au nanoparticles deposition on carbon-coated LiNi0.5Mn1.5O4 and its performance as a cathode material for Li ion batteries.

LiNi0.5Mn1.5O4 (LMNO) has attracted considerable attention as a Li-ion battery cathode material, owing to its high discharge voltage of 4.7 V (vs. Li/Li+) and high energy density. However, the electronic conductivity of LMNO is low, resulting in a low discharge capacity at high current density. To overcome this limitation, we deposited Au nanoparticles (NPs), which have a high conductivity and chemical stability at high battery voltages, on carbon-coated LMNO (LMNO/C) using ultrasound irradiation. Consequently, Au NPs that are ∼16 nm in size were deposited on LMNO/C, and ultrasound irradiation was reported to disperse the NPs on LMNO/C more effectively than stirring. Furthermore, the deposition of Au NPs on LMNO/C using ultrasound irradiation improved its electronic conductivity, which is related to an increase in the discharge capacity due to the reduction of Ni4+ to Ni2+ in LMNO/C at a high current density.

Gastric Cancer with Multiple Lymph Node Enlargement at the Time of the Sarcoidosis Diagnosis.

An 80-year-old woman was found to have a 40-mm depressed-type gastric cancer. Computed tomography showed multiple lymph node enlargement, including paraaortic lymph nodes. The extent of lymph node enlargement was significant compared with the depth of the primary lesion. We conducted distal gastrectomy, D2 lymph node dissection, and a paraaortic lymph node biopsy. Microscopically, the tumor was diagnosed as mucosal cancer. In the dissected lymph nodes, noncaseating granuloma was found without metastasis of adenocarcinoma. Immunohistochemical staining using Propionibacterium acnes-specific antibodies showed a large number of P. acnes-positive cells in the granulomas. Finally, the tumor was diagnosed as early-stage gastric cancer and sarcoidosis.

Severe cryoglobulinemia with cerebral infarction successfully treated with steroid and rituximab: A case report.

We report the case of severe cryoglobulinemia with cerebral infarction and ischemic cardiac disease successfully treated with steroid and rituximab.

Efficacy of Magnifying Narrow Band Imaging with Acetic Acid Spray in Diagnosing Superficial Non-Ampullary Duodenal Epithelial Tumors.

BACKGROUND/AIMS: The aim of the present study was to evaluate the efficacy of magnifying narrow band imaging with acetic acid spray (MA-NBI) in differentiating category 4/5 lesions from category 3 lesions of superficial non-ampullary duodenal epithelial tumors (SNADETs) as per Vienna Classification and to compare the diagnostic performances of both MA-NBI and magnifying narrow band imaging (M-NBI). METHODS: We retrospectively identified 60 resected SNADETs (31 category 3 lesions and 29 category 4/5 lesions) in 60 patients who underwent M-NBI and MA-NBI preoperatively. We evaluated vascular and surface patterns using M-NBI and MA-NBI for characterizing category 3 and 4/5 lesions. The surface pattern was classified as tubular, villous, or mix structure using MA-NBI. In addition, lesions with disorganized and unclear structures with irregular margins that can be clearly recognized by MA-NBI were defined as irregular surface structures. RESULTS: For MA-NBI, category 4/5 lesions had a significantly higher mix structure rate and higher irregular surface structure rate than category 3 lesions (62 vs. 16%, p < 0.001, and 86 vs. 19%, p < 0.001, respectively). The diagnostic accuracy of MA-NBI using mix and irregular surface structures for identifying category 4/5 lesions was as follows: sensitivity, 62/86%; specificity, 84/77%; positive predictive value, 78/78%; negative predictive value, 70/86%; and accuracy, 73/82%. The diagnostic accuracy of MA-NBI using irregular surface structure was significantly higher than that of M-NBI (p < 0.05). CONCLUSION: MA-NBI may be useful in differentiating between category 3 and category 4/5 lesions of SNADETs.

Gastric MiNEN Arising from the Heterotopic Gastric Glands.

An 80-year-old woman presented with a 30-mm protruding lesion-like submucosal tumor with a central depression located at the anterior wall of the upper gastric body. The depressed area had a well-demarcated margin, while the other area was covered by a non-neoplastic mucosa. A biopsy specimen revealed neuroendocrine carcinoma. Endoscopic ultrasonography revealed a heterogeneous mass with a clearly distinguished border in the submucosal layer. The mass had two distinct areas adjacent to each other. In addition, a hypoechoic zone was observed on the margin of the mass. Distal gastrectomy was performed. The final diagnosis was a mixed neuroendocrine-non-neuroendocrine neoplasm arising from the heterotopic gastric gland.

Optimal Number of Message Transmissions forProbabilistic Guarantee of Latency in the IoT.

The Internet of Things (IoT) is now experiencing its first phase of industrialization. Industrial companies are completing proofs of concept and many of them plan to invest in automation, flexibility and quality of production in their plants. Their use of a wireless network is conditioned upon its ability to meet three Key Performance Indicators (KPIs), namely a maximum acceptable end-to-end latency L, a targeted end-to-end reliability R and a minimum network lifetime T. The IoT network has to guarantee that at least R % of messages generated by sensor nodes are delivered to the sink with a latency ≤L, whereas the network lifetime is at least equal to T. In this paper, we show how to provide the targeted end-to-end reliability R by means of retransmissions to cope with the unreliability of wireless links. We present two methods to compute the maximum number of transmissions per message required to achieve R. M F a i r is very easy to compute, whereas M O p t minimizes the total number of transmissions necessary for a message to reach the sink. M F a i r and M O p t are then integrated into a TSCH network with a load-based scheduler to evaluate the three KPIs on a generic data-gathering application. We first consider a toy example with eight nodes where the maximum number of transmissions M a x T r a n s is tuned per link and per flow. Finally, a network of 50 nodes, representative of real network deployments, is evaluated assuming M a x T r a n s is fixed. For both TSCH networks, we show that M O p t provides a better reliability and a longer lifetime than M F a i r , which provides a shorter average end-to-end latency. M O p t provides more predictable end-to-end performances than Kausa, a KPI-aware, state-of-the-art scheduler.

Early-stage Neuroendocrine Carcinoma of the Esophagus Observed with Annual Endoscopy for Three Years.

An 80-year-old man was found to have a reddish depressed lesion on the middle thoracic esophagus. The morphology of the lesion had been almost unchanged for 3 years, but it transformed to a 2-cm depressed lesion with elevated margins and an irregular nodular surface. The lesion was resected endoscopically and ultimately diagnosed as a combined neuroendocrine carcinoma and squamous cell carcinoma with submucosal invasion. The patient was additionally treated with chemoradiotherapy but died of the primary disease eight months after the initial treatment. It is important to elucidate the natural history of this disease at an early stage.

Autoimmune pancreatitis with colonic stenosis: an unusual complication and atypical pancreatographic finding.

BACKGROUND: Type 1 autoimmune pancreatitis (AIP) often accompanies various systematic disorders such as sclerosing cholangitis, sialoadenitis, retroperitoneal fibrosis, interstitial pneumonitis and nephritis. Although rarely reported in acute pancreatitis, colonic stenosis is an uncommon complication in cases with AIP. CASE PRESENTATION: A 69-year-old Japanese man complained of abdominal pain and continuous diarrhea, resistant to intake of antimuscarinic and probiotic agents. A colonoscopy demonstrated a stenosis at the splenic flexure. Computed tomography revealed a focal enlargement of the pancreatic tail with a capsule-like rim, contacting with the descending colon. Endoscopic retrograde pancreatography (ERP) was unable to visualize the main pancreatic duct (MPD) at the pancreatic tail, despite a full contrast injection. A high serum IgG4 level (1060 mg/dL) and exclusion of pancreatic cancer by endoscopic ultrasound guided-fine needle aspiration suggested AIP, but did not fulfill the diagnostic criteria, and steroid therapy was initiated. One month after starting steroid intake, pancreatic swelling was minimized and the MPD was visualized by ERP, fulfilling the international consensus diagnostic criteria (ICDC) of AIP. Colonic stenosis was relieved and the patient's symptoms disappeared. CONCLUSION: The present case is the first report of AIP developing colonic stenosis by the inflammatory infiltration. In this case, steroid therapy was effective for the diagnosis and treatment of pancreatic mass involving the descending colon.

Is a "sulcus cut" technique effective for determining the level of distal femoral resection in total knee arthroplasty?

PURPOSE: Determining the level of distal femoral resection is crucial when performing total knee arthroplasty (TKA). However, variations in distal femoral resection are encountered unexpectedly. A "sulcus cut" technique is sometimes used to determine the level of distal femoral resection, but its effectiveness has not been evaluated. The aim of this study was to examine the reliability of the sulcus cut technique using computer simulation for preoperative planning. METHODS: This study group comprised 40 knees in 34 patients (22 women, 12 men) scheduled for TKA. The preoperative planning software of a computed tomography (CT)-based navigation system was used. We determined the resected level of the femur so that the bone-implant interface of the femoral component was adjusted to the deepest subchondral bone of the trochlear groove in coronal CT images. We then measured each perpendicular distance from the resected surface of the proximal femur to the most distal point of the lateral and medial femoral condyles. RESULTS: The mean distances of the distal-lateral and distal-medial condylar resections from the femoral sulcus were 7 mm (±1 mm) and 8 mm (±1 mm), respectively. The resection level did not differ significantly between men and women or between different component sizes. There was a slightly positive correlation between the femoral mechanical and anatomical axis angle and the distance of the distal-lateral condylar resection from the femoral sulcus. CONCLUSIONS: The sulcus cut technique can be used to determine the desirable level of the distal femoral resection in TKA. LEVEL OF EVIDENCE: Case series, Level IV.