Large ovarian tumor-caused failure of VA-ECMO in a patient with cardiac arrest related to massive pulmonary embolism.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) plays an important role in patients with massive pulmonary embolism (PE)-related cardiac arrest. A 47-year-old healthy Japanese woman was brought to the emergency department because of shock. The patient suddenly collapsed due to cardiac arrest in an ambulance. The patient was diagnosed with PE on transthoracic echocardiography during cardiopulmonary resuscitation (CPR). Emergency VA-ECMO cannulation was performed percutaneously. Although VA-ECMO support was initiated, the return cannula flow could not be pumped because of the high resistance. Circulation support with VA-ECMO was discontinued. Subsequently, pulmonary angiography under CPR revealed numerous thrombi in the bilateral pulmonary arteries, and aspiration thrombectomy and catheter fragmentation were performed. The patient achieved spontaneous recovery of circulation after successful catheter fragmentation. After the procedure to investigate the cause of VA-ECMO failure, whole-body computed tomography showed a large ovarian tumor and compression of the femoral artery and abdominal aorta. The patient died of multiple organ failure due to hypoxic encephalopathy. Undiagnosed gynecological tumors often cause fulminant PE and may also cause the failure of VA-ECMO due to vascular compression. Alternative cannulation sites and prior thrombolysis should be immediately considered. The complexity of PE management necessitates a well-trained PE response team. Learning objective: Large gynecological tumors may cause pulmonary embolism-related cardiac arrest and consequent failure of venoarterial extracorporeal membrane oxygenation using the femoral artery approach due to vascular compression by the tumor. An adequate strategy should be considered to achieve immediate recovery of spontaneous circulation and circulation support as simultaneous systematic thrombolysis and an alternative central cannulation approach to protect against hypoxic organ damage. The complexity of pulmonary embolism (PE) management necessitates a well-trained PE response team.

Electrosurgical knife with the water-jet function of tip-type during endoscopic treatment injection.

Objectives: This study aimed to objectively evaluate the water-jet-functioned electrosurgical knife injection performances in a desktop experiment. Methods: Five types of water-jet-functioned electrosurgical knives, including two injection styles of sheath-type (A: DualKnife J, KD-655L; B: FlushKnife, DK2620-J-B20S; C: Splash M-Knife, DN-D2718B; D: ISSEN, SN1650-20) and tip-type (E: ORISE ProKnife, M00519361) were evaluated. These knives were compared with an injection needle (Control: SuperGrip 25G) as a control. The injection speed under constant pressure and the injection efficiency for each knife against prepared porcine stomach mucosa were evaluated. The additional clear gel injections using an injection needle were observed using an indigo blue-colored gel to evaluate the difference between the locations of water-jet holes. Results: Four types of knives, except for A, showed significantly higher water-jet speeds (A: 0.79 ± 0.03 g/20 s, B: 2.56 ± 0.05 g/20 s, C: 3.09 ± 0.06 g/20 s, D: 2.86 ± 0.05 g/20 s, and E: 1.79 ± 0.03 g/20 s) compared to that of the control (1.21 ± 0.03 g/20 s). Meanwhile, significantly higher efficacy of injection was found in the tip-type water-jet function knife, second to the injection needle (Control: 37.2% ± 35.5%, A: 20.9% ± 20.2%, B: 1.1% ± 2.2%, C: 6.2% ± 12.6%, D: 12.5% ± 15.6%, and E: 33.3% ± 32.2%). An additional injection experiment revealed that the injection with a piercing tip into the gel could achieve sufficient additional injection inside the stacked clear gel. Conclusions: The tip-type water-jet function electrosurgical knife is preferable for effective submucosal injection during endoscopic treatments.

Two cases of wide QRS complex tachycardia caused by anamorelin.

Anamorelin is prescribed for cancer cachexia treatment. Anamorelin is a ghrelin receptor antagonist and exerts a sodium channel blockade effect, possibly inducing disorders of the cardiac conduction system. We herein report two cases of wide QRS complex tachycardia caused by anamorelin. In both cases, the patients had liver dysfunction. Anamorelin is mainly metabolized in the liver; hence, sodium channel blockade by anamorelin during liver dysfunction can cause serious side effects, including wide QRS complex tachycardia, similar to flecainide toxicity. The differential diagnosis of wide QRS tachycardia caused by anamorelin can be challenging because conventional electrocardiogram criteria cannot be applicable in patients with drug intoxication. It can worsen the situation for the use of antiarrhythmic drugs for wide QRS tachycardia. The appropriate treatment is supportive care until anamorelin is metabolized. To our best knowledge, this is the first study to report the life-threatening adverse effects of anamorelin. Learning objective: Anamorelin is prescribed for cancer cachexia treatment. Anamorelin can cause wide QRS complex tachycardia. Our findings in the two cases we encountered indicate that we should be aware of wide QRS complex tachycardia in patients taking anamorelin, especially if they have liver dysfunction. We should suspect the condition to be the adverse effect of anamorelin and monitor the electrocardiogram and blood test findings regularly to prevent this fatal side effect.

Radiographic characteristics of canine subungual keratoacanthoma.

Subungual keratoacanthoma (SKA) is a rare benign nail bed tumor in dogs, and its radiographic characteristics have not been reported based on the authors' review of the literature. The purpose of this multicenter, retrospective, observational, descriptive study was to describe the radiographic features of SKA in dogs. Twelve dogs for a total of 12 digits with histologically confirmed SKA met the inclusion criteria. The radiographs of the manus or pes were reviewed by two veterinary radiologists and one veterinarian. The radiology reports were interpreted based on a consensus. In six dogs, there was lysis of both the middle phalanx (P2) and the distal phalanx (P3), whereas in the other six dogs, there was only lysis of P3. In all dogs with osteolysis of P2, the lysis involved the distal articular surface. Osteolysis of P3 was more severe in the ungual process than in the ungual crest in all dogs. The margins of the lytic regions of P2 and P3 were well defined and smoothly marginated in most dogs. Expansile changes in the P3 crest were observed in 83.3% (10/12 dogs), and the nail of the affected digit was enlarged and deformed in 91.6% (11/12 dogs). In summary, the radiographic features of canine SKA include severe pressure resorption of the P3 ungual process, expansile change of the P3 ungual crest, and nail enlargement and deformation. With these radiographic features, SKA should be considered as a differential diagnosis.

Salvage from hemodialysis via percutaneous transluminal renal artery stenting for a jeopardized solitary functioning kidney: A case report.

Atherosclerotic renal artery stenosis (ARAS) causes resistant hypertension, progressively declining renal function, and cardiac destabilization syndromes, including heart failure. We report a patient who underwent successful percutaneous transluminal renal angioplasty (PTRA) for anuretic acute kidney injury (AKI) due to ARAS. This patient, admitted to our hospital with congestive heart failure, developed anuretic AKI and started hemodialysis 3 days after admission. Computed tomography and magnetic resonance angiograms showed total occlusion of the proximal right renal artery, with atrophy of the right kidney and severe stenosis of the proximal left renal artery. These findings suggested that only the left kidney was functioning. We performed PTRA of the left renal artery in which the culprit lesion causing the AKI appeared to be located. Using intravascular ultrasound, severe calcification in the ostium of the left renal artery and a necrotic core with plaque rupture in the culprit lesion were observed. Kidney function recovered immediately after revascularization, which permitted successful withdrawal of hemodialysis. There is no clear consensus regarding the indication for PTRA in patients with ARAS; however, our experience suggests that PTRA may be beneficial for patients with a jeopardized solitary functioning kidney. .

Saturated fatty acids and fatty acid esters promote the polymorphic transition of clarithromycin metastable form I crystal.

The phase transition of active pharmaceutical ingredients should be taken into account during manufacturing, processing- and storage, because different crystal forms lead to different physical properties of formulations. The phase transition of clarithromycin (CAM) metastable form I to stable form II was investigated on heating with additives such as fatty acids or fatty acid esters. Differential scanning calorimetry analyses revealed that when form I was heated with additives, the phase transition temperature of form I decreased close to the melting points of the additives. Powder X-ray diffraction analyses indicated the tentative presence of a non-crystalline component during the transition of form I to form II on heating with additives. These observations implied that CAM form I dissolved in the melted additives on heating and the dissolved CAM crystallized to form II. Reduction of transition temperatures in the presence of additives were also observed for the crystals of nifedipine form B and carbamazepine form III. These results suggested that the phenomena can be widely applicable for simultaneous crystalline phase transition and granulation using binder additives.

Clarithromycin highly-loaded gastro-floating fine granules prepared by high-shear melt granulation can enhance the efficacy of Helicobacter pylori eradication.

In an effort to develop a new gastro-retentive drug delivery system (GRDDS) without a large amount of additives, 75% clarithromycin (CAM) loaded fine granules were prepared with three different hydrophobic binders by high-shear melt granulation and their properties were evaluated. Granules containing the higher hydrophobic binder showed sustained drug release and were able to float over 24h. The synchrotron X-ray CT measurement indicated that both the high hydrophobicity of the binder and the void space inside the granules might be involved in their buoyancy. In an in vivo experiment, the floating granules more effectively eradicated Helicobacter pylori than a CAM suspension by remaining in the stomach for a longer period. In short, CAM highly-loaded gastro-floating fine granules can enhance the eradication efficiency of H. pylori compared with CAM alone.

Coronary stenting with cardiogenic shock due to acute ascending aortic dissection.

A 65-year-old man developed chest pain under cardiogenic shock. Coronary angiography revealed severe stenosis from the ostium of the left main coronary artery (LMCA) to the left anterior descending artery (LAD). Intravascular ultrasound (IVUS) identified a large hematoma that originated from the aorta and extended into the LAD, thereby compressing the true lumen. Type A aortic dissection (TAAD) that involved the LMCA was diagnosed by IVUS. Coronary stenting was performed via the LMCA to the proximal LAD, which resulted in coronary blood flow restoration and no further propagation of dissection. Elective surgical aortic repair was performed 2 wk after the stenting. LMCA stenting under IVUS guidance is effective for prompt diagnosis and precise stent deployment in patients with cardiogenic shock due to TAAD with LMCA dissection.

Fine granules showing sustained drug release prepared by high-shear melt granulation using triglycerin full behenate and milled microcrystalline cellulose.

This study aimed to prepare fine granules with a diameter less than 200µm and sustained drug release properties by melt granulation. Triglycerin full behenate (TR-FB) was examined as a new meltable binder (MB) by comparison of its properties with those of glycerin monostearate (GM), widely used as MB. The effect of milling microcrystalline cellulose (MCC), an excipient for melt granulation, on the granule properties was also investigated. TR-FB was more stable during heating and storage than GM, and produced smaller granules with narrower particle size distribution, larger yield in the 106-200µm range, uniform roundness and better sustained drug release profile than those prepared with GM. Granules prepared with milled MCC had almost the same physicochemical properties as those produced with intact MCC. However, milled MCC produced granules with a more rigid structure and smaller void space than intact MCC. Consequently, the granules produced with milled MCC showed better sustained drug release behavior than those prepared with intact MCC. We successfully prepared fine granules with sustained drug release properties and diameter of less than 200µm using TR-FB and milled MCC.

Respiratory-gated ¹8F-FDG PET/CT for the diagnosis of liver metastasis.

PURPOSE: To ascertain the role of respiratory-gated PET/CT with (18)F-fluorodeoxyglucose ((18)F-FDG) for accurate diagnosis of liver metastasis. MATERIALS AND METHODS: Forty patients with suspected liver metastasis underwent conventional whole-body PET/CT scan initially, followed by respiratory-gated PET/CT scan covering the liver. Visual detectability (using a 5-point confidence scale), maximum standardized uptake value (SUVmax) and metabolic tumor volume (MTV) of hepatic metastatic lesions were assessed for three data sets including ordinary whole-body (WB) scan, and non-respiratory-gated (nRG) and respiratory-gated (RG) scans. Results of enhanced CT and/or MRI, or clinical and radiological follow-up were used for reference. RESULTS: Sixteen of the patients were found to have 53 metastatic lesions in the liver. Patient-based accuracy of WB, nRG, and RG was 92.5%, 95.0%, and 97.5%, respectively, with a lesion-based detection rate of 67.9%, 73.6%, and 73.6%, respectively. The average SUVmax of 34 liver metastatic lesions for WB, nRG, and RG was 6.60 ± 2.34, 7.19 ± 2.66, and 8.08 ± 3.24, respectively. SUVmax for RG was significantly higher than that for WB (p=0.0069). The average MTV of these 40 lesions for the three protocols was 5.32 ± 4.78 cm(3), 5.07 ± 4.73 cm(3), and 4.73 ± 4.67 cm(3), respectively. Among the three protocols, RG showed the best visual and quantitative evaluation for diagnosis of liver metastasis. CONCLUSION: Respiratory-gated PET/CT allows more accurate identification of liver metastases than non-respiratory-gated PET/CT.

Successful coronary stenting in anomalous right coronary artery by using an inner catheter with mother and child technique under multislice CT guidance.

The ectopic location and unusual coronary course of the anomalous right coronary artery (RCA) from the left sinus of Valsalva makes percutaneous coronary intervention difficult. In this report, we describe a case of successful stent implantation in an anomalous RCA performed using a 4.5F inner catheter with a 6F guiding catheter used in the mother and child system under the guidance of multislice computed tomography. This approach was found to be safe and feasible in cases involving anomalous coronary origin because of the excellent engagement and support provided by the guiding catheter.

Cardiogenic shock due to takotsubo cardiomyopathy associated with serotonin syndrome.

A 65-year-old woman, with valvular heart disease, atrial fibrillation, and depression, presented to the emergency room due to dyspnea with shock state accompanied by agitation. An electrocardiogram showed ST segment elevation in leads II, III, aVF, I, aVL, and V4-6. An echocardiography revealed extensive akinesis in the apex, but hyperkinesis in the base, with apical ballooning appearance. An emergent coronary angiography showed no obstructive disease. The patient required intubation under mechanical ventilator, and an intra-aortic balloon pump to recover from shock state. She had been taking maprotiline, a tetracyclic antidepressant, and had added dextromethorphan, a cough suppressant, just before admission. The patient was diagnosed with takotsubo cardiomyopathy associated with serotonin syndrome due to serotonergic drug interactions. After discontinuation of these drugs and administration of serotonin antagonist under mechanical supportive care, she became hemodynamically stable. Apical ballooning was completely resolved 2 weeks later, and she was discharged well. We diagnosed serotonin syndrome manifesting as excessive serotonin toxicity that resulted in a hyperserotonergic and hyperadrenergic state, causing takotsubo cardiomyopathy. Here, we report a case of takotsubo cardiomyopathy associated with serotonin syndrome. This case suggests that serotonin syndrome should be recognized promptly and complications, including takotsubo cardiomyopathy, need to be treated appropriately. .

[Effusive constrictive pericarditis successfully treated by partial pericardiectomy with left thoracotomy; report of a case].

A 72-year-old male was admitted to our hospital due to high fever and dyspnea. Echocardiography and bacterial culture of pericardial fluid revealed purulent pericarditis caused by Streptococcus. Despite pericardial drainage and antibiotic therapy, hemodynamic instability due to constriction persisted. At 12th hospital day, partial pericardiectomy with left thoracotomy was performed. After the operation, his hemodynamics improved gradually, and was discharged from the hospital on the 54th post operative day without recurrence of infection nor constriction.

Calcified plaque rupture and very late stent thrombosis after bare-metal stent implantation.

Very late stent thrombosis (>1 year: VLST) is a major concern in the drug-eluting stent (DES) era. VLST occurs not only in patients implanted with DESs but also in those implanted with bare-metal stents (BMSs). We examined intravascular ultrasound (IVUS) findings in patients with VLST after BMS implantation. Five consecutive patients presented with VLST as ST elevation myocardial infarction. VLST occurred at a mean of 9.5 years after BMS implantation. In the IVUS findings, the minimum stent area was 7.8 ± 1.2 mm(2). None of the patients had incomplete stent apposition or stent underexpansion, which was defined as a stent expansion index of <0.8. The mean stent expansion index was 1.01. Calcium deposits in the previous stented segment were observed in 4 patients (80%), and a total of 14 calcium deposits were observed in all patients. The calcification pattern was superficial (78.5%) and spotty (57.1%) within a calcium arc of <90°. The mean calcium arc was 72.5° ± 88.5°. A ruptured plaque with an intraluminal flap was detected in all cases. According to the IVUS findings of ruptured plaque and calcium deposits, VLST after BMS might be caused by a thrombus formation subsequent to a calcified atherosclerotic plaque rupture.

Cavotricuspid isthmus conduction split by pouch-like recesses during typical atrial flutter.

A 58-year-old man had typical cavotricuspid-isthmus-dependent atrial flutter (AFL). Right atrial angiography and multidetector computed tomography revealed a deep pouch-like recess in the mid-isthmus region. Linear ablation from the pouch to the edge of the inferior vena cava resulted in widely split double potentials without any change in the AFL cycle length. This observation suggested that the pouch played an electrophysiological role by dividing the flutter wavefront into 2 parallel conduction wave fronts through both sides of the pouch along the isthmus during typical AFL. When a widely split potential is created on 1 side of the pouch, the other side of the pouch should be targeted.