Hanwa Memorial Hospital

Spinal epidural lymphoma is a rare pathological entity that usually responds well to chemotherapy. However, it occasionally requires immediate surgical treatment for progressive neurological symptoms caused by a bulky epidural mass and bone destruction. In the management of spinal epidural lymphoma, the role of surgical interventions has not yet been fully defined, and few reports on long-term functional outcomes are available. We report 3 cases of thoracic spinal epidural lymphoma that required emergent surgical management for neural decompression and were followed postoperatively over 2 years or until death. Two patients (cases 1 and 2) underwent spinal instrumentation to prevent subsequent spinal deformity, whereas instrumentation was avoided in case 3 due to atopic dermatitis, which increases the risk of surgical site infection. During the 2-year postoperative period, 2 patients (cases 1 and 3) maintained disease-free survival and achieved sufficient neurological recovery to remain ambulant, while the other patient (case 2) died due to spinal epidural lymphoma relapse. Given the high treatment responsiveness and the potential for long-term disease-free survival in spinal epidural lymphoma, treatment should aim to maximize functional outcomes. Prompt surgical decompression is mandatory in patients with neurological deficits. Although spinal instrumentation is typically recommended to prevent spinal deformity, it should be withheld if it poses a risk of delaying chemotherapy, such as in cases with a high risk of surgical site infection. Therefore, spinal surgeons play several essential roles in managing spinal epidural lymphoma from the acute to the chronic phase, aiming to improve patients' prognosis and quality of life.

BACKGROUNDAlthough acute pancreatitis and walled-off necrosis (WON) are rare complications following aortic surgery, they are serious risk factors for postoperative mortality. Considering the poor general condition of the postoperative patient, more effective and less invasive treatments are favorable.CASE SUMMARYA 67-year-old man was referred to our hospital for the treatment of WON after acute pancreatitis. He had undergone total aortic arch replacement due to aortic arch aneurysm and coronary artery bypass grafting due to angina pectoris 6 weeks prior in another hospital. On the second postoperative day, laboratory data and computed tomography showed that the patient had developed acute pancreatitis. Although conservative management (antibiotics, hydration, etc.) had helped in relieving the symptoms of acute pancreatitis, peripancreatic fluid collection (PFC) persisted, accompanied by duodenal obstruction and vomiting. Contrast-enhanced computed tomography showed that the heterogeneous enhancement and fluid collection in the pancreatic body and tail had increased, consistent with walled-off WON. We therefore performed endoscopic ultrasound-guided transluminal drainage for the PFC. As a result, the WON resolved gradually, resulting in improved oral intake.CONCLUSIONAcute pancreatitis is a rare gastrointestinal complication following thoracic and thoracoabdominal aortic aneurysm surgery. To the best of our knowledge, this is the first case of WON after aortic arch surgery treated with endoscopic ultrasound-guided transluminal drainage for PFC.

Introduction: We report an exceedingly rare case of hepatocellular carcinoma (HCC) associated with an idiopathic congenital forearm arteriovenous fistula (AVF). Given the absence of previous reports addressing the treatment of HCC in patients with AVF, we evaluate HCC treatment strategies, including the appropriateness of using angiogenesis inhibitors. Case Presentation: A 74-year-old man was admitted for the evaluation of liver tumors. His medical history included a chronic, intractable idiopathic right forearm AVF, for which he had undergone multiple surgical interventions. Abdominal EOB-MRI revealed multiple small focal lesions across both liver lobes during the hepatobiliary phase, indicative of multiple HCC, and liver biopsy confirmed early-stage HCC. Considering the potential presence of additional vascular anomalies similar to the forearm AVF, local hepatic artery chemoembolization was performed. Since there is still insufficient discussion about the systemic administration of angiogenesis inhibitors to patients with vascular abnormalities such as AVF, we discuss the treatment options for HCC with AVF, including its strategies in the progressed HCC stage. Conclusion: As molecularly targeted therapies continue to evolve, recognizing the unique aspects of cases like ours is crucial. Establishing an appropriate treatment strategy for HCC patients with AVF is imperative, highlighting the need for tailored therapeutic approaches based on individual vascular profiles.

BackgroundPatients with heart failure (HF) with mildly reduced or preserved ejection fraction in Asia may have different clinical characteristics and outcomes compared with patients from other parts of the world. ObjectivesThe purpose of this study was to investigate the clinical characteristics, safety, and efficacy of dapagliflozin in patients in Asia vs outside Asia in the DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure) trial. MethodsIn the DELIVER trial, patients with HF and left ventricular ejection fraction >40% were enrolled across 353 sites in 20 countries. The effects of dapagliflozin vs placebo on primary (composite of worsening HF or cardiovascular death) and secondary outcomes were compared in patients from Asia vs outside Asia. ResultsAmong 6,263 participants, 1,226 (19.6%) were enrolled in Asia. Participants from Asia were less likely to have diabetes, hypertension, history of myocardial infarction, or obesity. After adjusting for clinically relevant characteristics, those in Asia had similar risks of primary composite outcome compared with those from outside Asia (HR: 0.97; 95% CI: 0.82-1.15). Those in Asia had a lower risk of all-cause mortality compared with those enrolled outside Asia (HR: 0.54; 95% CI: 0.44-0.66). Enrollment from Asia did not modify the effect of dapagliflozin on the primary outcome (Pinteraction = 0.54). Serious adverse events and rates of drug discontinuation were also balanced in both treatment arms, irrespective of enrollment in Asia vs outside Asia. ConclusionsIn the global DELIVER trial, dapagliflozin reduced the risk of CV death or worsening HF events and was well tolerated among participants enrolled in both Asia and other geographic regions.

Background: The ketamine metabolite 2R,6R-hydroxynorketamine (HNK) has recently attracted increasing attention by its potential as a novel fast-acting antidepressant candidate to treat depression. HNK has anti-inflammatory properties which contribute to its protective effects against ischemia and reperfusion (I/R) injury. However, whether HNK produces beneficial effects on myocardial I/R injury has not been elucidated yet. Here we tested the hypothesis that HNK might protects the heart from myocardial I/R injury by limiting myocardial inflammation. Methods and Results: Twelve male C57BL/6J mice (8-10 weeks old, 20-25 g) were used to produce acute myocardial I/R (30 min/24 h) by micro-surgery. Mice were divided into four groups: Sham, HNK+Sham, I/R, HNK+I/R. A single-dose of HNK (30 mg/kg) was intraperitoneally injected one hour before the I/R. Echocardiographic imaging and TTC staining showed that HKN administration before myocardial I/R increased fraction shortening by 26.5% and limited infarct size by 40% compared to I/R alone. Proteomics analysis showed HNK caused 81 proteins down-regulated and 18 proteins up-regulated in the left ventricle after I/R (HNK+I/R vs . I/R). The gene name of the top 5 down-regulated proteins are Ighg2b, Igkv17-121, Igkc, Igtp and Cd68. The go enrichment analysis showed that HNK in the I/R group could modulate immune response via downregulating signal transducer and activation of transcription 1 and 2 (STAT1 and STAT2) and type 1 interferon pathway. The KEGG enrichment analysis showed that HNK affected antigen processing and presentation via down-regulating beta-2-microglobulin, TAPBP and TAP1/2. Cytokine analysis showed that HNK attenuated the increased tissue levels of TNF-alpha, IL-1 beta, CTnI and BNP induced by I/R. HNK also significantly decreased I/R induced-neutrophil infiltration, apoptosis and oxidative stress in the myocardium as detected by Ly6G staining, tunel staining and DHE probe staining. Conclusion: We demonstrated for the first time the administration of HNK regulates immune response through STAT1 and STAT2 and type 1 interferon pathway in the heart, leading to the cardioprotection against I/R injury. The use of HNK may become an immunomodulatory therapy for the ischemic heart disease.