Fujieda Municipal General Hospital

A 73-year-old woman presented with cervical lymphadenopathy. A biopsy of the affected lymph node showed the diagnosis of adult T-cell leukemia/lymphoma (ATLL). While treatment was planned, she developed rapid-onset consciousness disturbance and gait disorder 1 week before the initiation of therapy, leading to emergency hospitalization. Computed tomography showed a hypodense lesion in the midbrain, and a cerebrospinal fluid analysis showed ATLL cells, resulting in a diagnosis of central nervous system infiltration of ATLL. High-dose methotrexate plus cytarabine therapy was administered. However, this therapy was ineffective, and the patient died on hospital day 21. An autopsy showed that the midbrain tumor was an Epstein-Barr virus-positive primary central nervous system lymphoma. Although there have been reports of primary central nervous system lymphoma developing during the treatment course of ATLL, to the best of our knowledge, this is the first reported case of concurrent onset of both diseases.

Anticoagulant effects of direct oral anticoagulants (DOACs) are influenced by their plasma levels and anti-factor Xa (FXa) activity. Delayed bleeding is a major adverse event associated with endoscopic mucosal resection (EMR) of colorectal neoplasms. However, the association between post-EMR bleeding and pharmacodynamics in patients taking DOAC remains unknown. This study investigated the association between pharmacological risk factors and delayed bleeding in patients receiving DOAC. This multicenter prospective trial in Japan evaluated the incidence of post-EMR delayed bleeding in DOAC users between April 2018 and May 2022 and determined the association of post-EMR delayed bleeding with plasma levels and FXa activity. The incidence of post-EMR delayed bleeding was 10.5% (95% confidence interval [CI]: 5.3%-18.0%). There were large individual differences in plasma levels and FXa activity for each DOAC. At the trough and Tmax, plasma DOAC levels and plasma level/dose ratios were significantly correlated with FXa activity. Multivariate analysis showed that high anticoagulant ability was a risk factor for post-EMR delayed bleeding (adjusted OR, 12.211; 95% CI: 1.081-137.922, p = 0.043). DOAC users with high anticoagulant activity may be at higher risk of post-EMR delayed bleeding from colorectal neoplasms.

The craniovertebral junction (CVJ) is anatomically complex, protecting important neural and vascular structures while providing a high degree of multidirectional motion. 1 This region is not only prone to age-related changes, but also susceptible to spinal tumors, vascular malformations, and pathologies associated with congenital anomalies.Advances in preoperative imaging evaluation, surgical techniques, and intraoperative support devices have made it possible to perform safer and more sophisticated surgery, but there is still a risk of life-threatening complications.Therefore, surgery in this region requires more highquality treatment strategy considering the pathophysiology of the disease as well as the unique anatomy and biomechanical properties.This special issue "CVJ Challenges" focuses on complicated neurospinal surgery in the CVJ which still remains relatively unknown and controversial in terms of appropriate management.Five articles in this special issue demonstrate an update on the current status of surgery in the CVJ, incorporating cutting-edge techniques and equipment for intractable lesions.These articles provide useful information featuring advanced approaches to intramedullary spinal cord tumors and spinal neoplasms occurring at the CVJ, updated surgical indications for Chiari malformations, and strategies for kyphotic deformities in this region, alongside a historical overview and evolution of spinal fixation techniques.For intramedullary cavernous angiomas with laterality, it has been reported that even in high cervical lesions, the posterolateral sulcus approach is a rational and safe method that aims for complete resection. 2However, challenges remain in the removal of ventrally located angiomas.While motor evoked potentials serve as an important prognostic tool in spinal surgery, they do not necessarily reflect actual motor function with precision in cases of intramedullary tumors. 3This highlights the importance of balancing the results of intraoperative neurophysiological monitoring with the microscopic findings of the spinal cord parenchyma. 2Regarding vertebral body tumors extending from the clivus to C2, transnasal surgical techniques have become increasingly established. 4Appropriate patient selection based on anatomical landmarks is crucial, and improved endoscopic visualization and surgical proficiency have enabled favorable resection outcomes. 5This anterior approach is considered optimal, particularly in minimizing postoperative airway and swallowing dysfunction.In the treatment of Chiari malformation type I, posterior fossa decompression remains the standard procedure.However, surgical strategies based on a novel classification that incorporates posterior fossa volume, hindbrain configuration, and stability in the CVJ Neurospine

Percutaneous transluminal angioplasty (PTA) for dysfunctional radial cephalic arteriovenous fistulas (RC-AVF) is associated with severe pain. This study evaluates the effectiveness of ultrasound-guided selective cutaneous nerve block (SCNB) in reducing procedural pain. A total of 292 dialysis patients with RC-AVFs undergoing 292 PTA procedures were retrospectively reviewed. Patients were categorized into three groups based on the anesthesia method: infiltration anesthesia (IA, n = 50), ultrasound-guided infiltration anesthesia (USIA, n = 74), and USIA combined with SCNB (USIA + SCNB, n = 168). SCNB targeted the lateral antebrachial cutaneous nerve (LACN) in all cases, with additional superficial radial nerve (SRN) blocks performed in 106 cases at the operator's discretion. Ultrasound imaging with an 18 MHz linear probe was used to visualize nerves and veins, and 1% lidocaine was administered using a 25G 25 mm needle. Pain was assessed using the Numerical Rating Scale (NRS). No significant differences in baseline characteristics were observed among the IA, USIA, and USIA + SCNB groups. The mean NRS pain scores during balloon inflation were significantly lower in the USIA + SCNB group (2.33 ± 2.08) compared to the IA group (5.24 ± 2.34, p < 0.001) and the USIA group (4.14 ± 2.70, p < 0.001). Among 38 cases with isolated forearm lesions, there was no significant difference between LACN-only and LACN + SRN blocks (2.42 ± 2.04 vs 2.63 ± 1.92, p = n.s.). However, in 75 cases with isolated peri-anastomotic lesions, the addition of an SRN block significantly reduced pain compared to LACN block alone (1.77 ± 1.82 vs 3.00 ± 1.78, p < 0.05). SCNB, particularly LACN block for forearm stenosis and combined LACN + SRN block for peri-anastomotic lesions, effectively reduces pain during PTA of RC-AVFs. When combined with USIA, SCNB further enhances analgesic effectiveness during PTA, and the two methods demonstrate a synergistic effect. This method provides safe, motor-sparing anesthesia, improving patient comfort in endovascular procedures.

Listeriosis during pregnancy is rare but can lead to premature miscarriage and intrauterine fetal death. A 29-year-old pregnant woman at 29 weeks of gestation was transferred to our hospital because of mild fever and abdominal pain. Emergency cesarean section was performed due to non-reassuring fetal status concomitant with suspected intrauterine infection. An unusually bright yellow amniotic fluid was observed. The oropharyngeal cavity of the neonate was occupied by thick, tenacious yellow mucus, making its removal challenging. The neonate was intubated due to poor oxygenation. Neonatal blood cultures revealed Listeria monocytogenes. Gram staining of cerebrospinal fluid was negative. The neonate was treated and discharged on the 65th day after birth. The mother had a fever of 39.4°C on the first day after surgery; however, no other significant incident occurred. She was discharged on the 10th day after surgery. Placental pathology revealed funisitis, chorioamnionitis, and marginal deciduitis without evidence of villitis, suggesting predominant transvaginal rather than hematogenous infection. Scanning electron microscopy using NanoSuit imaging revealed Listeria monocytogenes in the amniotic epithelium. The presence of Listeria monocytogenes has been reported in foods stored in refrigerators for extended periods of time and in ready-to-eat meals; therefore, it is difficult for pregnant women to be aware of all potential risks. It is important for physicians to recognize that listeriosis may have a long incubation period and present with mild maternal symptoms. Nevertheless, it should be considered as a differential diagnosis. Routine and prompt identification of the causative organism through amniotic fluid and placental swab cultures is important, particularly when intrauterine infection is suspected. Moreover, pathological examination of the placenta can provide insights into the potential route of infection.