Jōetsu General Hospital

Herein, we present 3 cases of Rathke's cleft cysts that shrank spontaneously within a short period. In addition, we present a literature review, discussing the characteristics and of action mechanisms of rapid Rathke's cleft cyst regression. Case 1 was that in a 17-year-old boy diagnosed with an Rathke's cleft cyst on the basis of magnetic resonance imaging. The Rathke's cleft cysts had expanded to compress the optical chiasm. Therefore, surgical intervention was planned. However, without any medical treatment, magnetic resonance imaging performed 3 months later revealed a spontaneous reduction in size, and surgery was canceled. Case 2 was in a 10-year-old boy who presented with a severe headache. Surgery was planned for a sellar cystic lesion; however, magnetic resonance imaging performed 2 months later revealed spontaneous shrinkage without any treatment. The patient's symptoms disappeared, and the surgery was canceled. Case 3 was in a 25-year-old man who presented with a headache. Magnetic resonance imaging at presentation revealed a cystic lesion in the sella turcica, but repeat magnetic resonance imaging 4 months later revealed spontaneous shrinkage. Fifty-nine cases of spontaneously shrinking Rathke's cleft cysts, initially characterized by severe headache (54.2%), have been reported; of these, 57% of cases were in patients younger than 39 years. Furthermore, 64% of patients showed evidence of cyst reduction on magnetic resonance imaging within 6 months. Type 1-weighted magnetic resonance imaging scans showed isointensity or high signal intensity in 91% of cases. In conclusion, spontaneous shrinkage of Rathke's cleft cysts can occur within a few months. Type 1-weighted images are characterized by high signal intensity, and episodic headaches may indicate shrinkage. The possibility of short-term regression of Rathke's cleft cyst should be considered before scheduled surgery.

Abstract Background: This study aimed to examine the effects of preoperative interventions in lung cancer patients with untreated chronic obstructive pulmonary disease (COPD). This study evaluated the efficiency of preoperative interventions using tiotropium or umeclidinium/vilanterol (UMEC/VI) and included more patients than in previous studies on this topic.Methods: We conducted a two-center retrospective study. Perioperative forced expiratory volume in 1 second (FEV1) was compared between a preoperative COPD intervention group and an untreated group. COPD therapeutic drugs were started 2 weeks before surgery and were continued until 3 months after surgery. Radical lobectomy was performed in patients with an FEV1 of ≥1.5 L. Results: A total of 92 patients were enrolled (untreated, 31 patients; intervention, 61 patients). In the intervention group, 45 (73.8%) patients were prescribed the UMEC/VI intervention and 16 (26.2%) received TIO. The intervention group showed a greater increase in FEV1 than the untreated group (FEV1: 120 vs. 0 mL, P = 0.014). In the intervention group, the UMEC/VI group showed a greater increase in FEV1 than the TIO group (FEV1: 160 vs. 7 mL, P = 0.0005). In 9 of 15 (60.0%) patients with an FEV1 of <1.5 L before intervention, FEV1 increased to ≥1.5 L after intervention. Postoperative FEV1 in the intervention group was similar to that before intervention, unlike in the untreated group (−0.05 vs. −0.25 mL, P = 0.0026). Moreover, the FEV1 in the untreated group was similar to the preoperative predicted value, whereas that in the intervention group was significantly higher than the predicted value (+0.33 vs. +0.04 mL, P < 0.001)Conclusions: In lung cancer patients with untreated COPD, aggressive preoperative intervention improved respiratory function, expanded treatment options, and maintained respiratory function to a degree that exceeded preoperative predictions. Trial registration: retrospective registered

Immune-checkpoint inhibitors (ICI), including nivolumab and pembrolizumab, are among the standard treatments for previously treated advanced gastric cancer (AGC). This study aimed to evaluate the frequency of immune-related adverse events (irAEs) and the correlation between irAEs and their efficacy in AGC cases. Patients were divided into two groups according to irAE occurrence. The frequency of irAEs and the treatment outcome (response rate [RR], progression-free survival [PFS], and overall survival [OS]) were evaluated. The survival rates were evaluated by landmark analysis considering lead-time bias. Among 108 patients who received nivolumab or pembrolizumab, 17 (15.7%) had irAEs. In a 4-week landmark analysis, the RR, median PFS, and median OS were 28.5%, 3.9 months (95% CI=2.8-9.3), and 12.2 months (95% CI=3.8-NA) in patients with irAEs, while 3.0% (2/65), 1.8 months (95% CI=1.4-2.1), and 3.5 months (95% CI, 2.9-5.1) in patients without irAEs, respectively. In multivariate analysis, irAEs were associated with better PFS (HR=2.08, 95% CI=1.34-3.21). The occurrence of irAEs was associated with a better clinical outcome of ICIs in patients with AGC.

BackgroundTo assess the potential of the ultrasonographic sliding lung sign to detect severe intrathoracic adhesions before surgery.MethodsThis was a prospective, single-center, observational study including all patients aged 20–89 years undergoing elective thoracic surgery. Patients with pneumothorax, pyothorax, hemothorax, chylothorax, and hydrothorax were excluded. We recorded the ultrasound sliding lung sign, surgical characteristics, and follow-up parameters: past medical history, respiratory function, chest X-ray findings, and computed tomography (CT) findings. Severe intrathoracic adhesion was defined as the need for adhesiolysis requiring more than 30 minutes.ResultsA total of 168 patients consented to participate. All 15 patients without the sliding lung sign had hard severe adhesions [specificity 100%, sensitivity 88.2%, positive predictive value (PPV) 100%, negative predictive value (NPV) 98.7%, and area under curve (AUC) 0.94]. There were two false-negative results, both of which were soft adhesions. Although blunting of the costophrenic (CP) angle, CT findings, past medical history, and restrictive lung disease were identified as significant risk factors of severe intrathoracic adhesion, all areas under the curve were low (0.71, 0.71, 0.69, 0.61, respectively). Thoracotomy frequency, intraoperative bleeding, operative time, and postoperative hospitalization were significantly greater in these patients than in those with non-severe adhesions.ConclusionsThe ultrasound sliding lung sign could be used to predict severe intrathoracic adhesions before surgery. Preoperative confirmation of the ultrasound sliding lung sign is important for planning surgical approaches and implementing appropriate safety management.

Valproic acid (VPA) is not only an antiepileptic drug but also a mood stabilizer for patients with bipolar disorder. Long-term VPA therapy can cause carnitine deficiency, which may result in an increase in the blood ammonia level, in patients with epilepsy. However, information about this effect in patients with bipolar disorder is limited. The aim of this study was to investigate the associations between the serum VPA level and the carnitine and ammonia levels in psychiatric adult patients with epilepsy. The subjects were 182 consecutive Japanese adult patients (mean age 54.3 ± 19.5 years) diagnosed with bipolar disorder and treated with VPA. The serum VPA level, carnitine fraction, and plasma ammonia level were measured. Furthermore, the free carnitine and acylcarnitine fractions were measured using an enzyme cycling method. Sixty-nine patients (38%) had a low free carnitine level. There were significant differences in sex, height, VPA dose, serum VPA level, total carnitine level, acylcarnitine level, and acylcarnitine/free carnitine ratio between patients with a low free carnitine level and those with a normal range of free carnitine. The simple and multiple regression analyses revealed that the VPA dose and the serum VPA level were inversely and significantly correlated with the free carnitine level. The plasma ammonia level was correlated with the VPA dose, serum VPA level, and acylcarnitine level but not with the free carnitine level. These findings suggest that carnitine deficiency is associated with the VPA dose and the serum VPA level in patients with bipolar disorder. However, it is unlikely that carnitine deficiency is associated with hyperammonemia in patients with bipolar disorder.

本研究では，薬の安全性について議論する場合に医師がどのような知識を薬剤師に期待しているのか検討を行なった。新潟県上越地域にある2つの総合病院に勤務する専攻医以上の常勤医を対象とした。専門分野および専門以外の分野についてそれぞれ11の学習項目を設定して多肢選択式のアンケート調査を行ない，各項目において「必要な知識」または「把握すべき知識」を選択した医師の割合を求めた。81名の医師を対象にアンケート調査を行ない，そのうち71名から回答を得た（回収率87.7％）。その結果，「添付文書」は専門分野で95.8％および専門以外の分野で85.9％と最も高かった。次いで，「本邦のガイドライン」（専門分野78.9％，専門以外64.8％），「インタビューフォーム」（専門分野60.6％，専門以外49.3％），「ブルーレター・イエローレター」（専門分野54.9％，専門以外47.9％），および「最近の国内学会のトピック」（専門分野54.9％，専門以外35.2％）の順に高かった。専門分野において平均48.0％，また専門以外の分野において平均36.5％であり，専門分野の方が有意に高かった（P<0.001）。薬剤師が医師に情報提供する際には，添付文書やインタビューフォームなどの基本的な情報に加えて国内ガイドラインや国内学会のトピックを引用することで医師との共通言語が生まれ，議論が円滑に進む可能性がある。

A 73-year-old Japanese woman with untreated Graves' hyperthyroidism developed glucocorticoid-induced adrenal insufficiency (AI) after a supraphysiological dose of prednisolone therapy for bronchial asthma. Days later, she had high plasma adrenocorticotropic hormone (ACTH) levels and was expected to recover from glucocorticoid-induced AI. Her plasma ACTH levels remained high over 3 months during a physiological dose of hydrocortisone replacement. However, she suffered a further decrease in her serum cortisol level and was diagnosed with isolated adrenocorticotropin deficiency (IAD), in which bioinactive ACTH likely caused the high ACTH value. IAD should be considered as an unusual disorder associated with Graves' disease, especially in older patients.

Previous longitudinal studies have demonstrated that blood pressure measurements at home (HBP) in the wakening- up display stronger predictive power for death, and vascular complications in patients with type 2 diabetes mellitus (T2DM) than clinic blood pressure measurements (CBP). The leading cause of death was cancer. Patients with T2DM have associated with cancer, and high CBP is a risk factor for cancer. Therefore, this study investigated whether HBP or CBP is related to cancer event in patients with T2DM for 10 years. At baseline, 400 Japanese patients with T2DM were classified as hypertensive (HT) or normotensive (NT) based on HBP and CBP. Mean (± SD) duration was 95 ± 35 months. Primary and secondary endpoints were death and cancer, respectively. Differences in outcome between HT and NT were analyzed using survival curves from Kaplan-Meier analysis and log-rank testing. Associated risk factors were assessed using Cox proportional hazards. On basis of HBP, death and event of cancer were significantly higher in HT than in NT. The leading cause of death was cancer. On basis of CBP, there was no significant difference in the incidence of death and event of cancer between patients with HT and NT at baseline. Associated risk factor for cancer was T2DM. Home morning HT may be reflected more keenly state of cancer than clinic HT, which may be superior to clinic NT. When we meet with such patients, it is important that cancer may be one of many causes for morning HT in Japanese patients with T2DM.