Miyazaki Prefectural Hospital

BackgroundCoronary artery dissection during percutaneous coronary intervention (PCI) may lead to haemodynamic collapse. Intravascular ultrasound (IVUS)-guided tip detection-antegrade dissection re-entry (TD-ADR) may serve as a bailout strategy. We describe a unique case in which IVUS-guided TD-ADR successfully achieved true lumen re-entry after severe coronary artery dissection.Case summaryA 64-year-old woman who had received long-term immunosuppressive therapy for rheumatoid arthritis was admitted for unstable angina. Subsequent evaluation revealed severe multivessel disease, and the patient underwent PCI of the left anterior descending artery (LAD). During the procedure, the patient experienced cardiac arrest, likely due to worsening global myocardial ischaemia, and required venoarterial extracorporeal membrane oxygenation support. IVUS demonstrated subintimal wire tracking with true lumen collapse. IVUS-guided TD-ADR using a high-penetration chronic total occlusion wire supported by a microcatheter enabled precise re-entry into the true lumen and successful LAD revascularization. Severe left circumflex artery stenoses were also considered to perpetuate myocardial ischaemia and haemodynamic instability, necessitating rescue PCI for haemodynamic stabilization. In addition, major bleeding complications due to guidewire-induced perforation of the right subclavian artery branch were managed using stenting and coil embolization. The patient showed recovery of left ventricular function and was discharged in stable condition. During the 8-month follow-up after discharge, the patient was free of adverse events.DiscussionThis case highlights the feasibility of IVUS-guided TD-ADR as a bailout technique for coronary artery dissection during complex PCI. By enabling accurate true lumen re-entry, this approach facilitates timely revascularization and contributes to haemodynamic stabilization and recovery in a life-threatening setting.

Rituximab is frequently used to treat hematological and autoimmune diseases. Rituximab-induced acute thrombocytopenia (RIAT) is a rare adverse event associated with the use of this drug. In this report, we describe two cases of RIAT in patients with systemic sclerosis. Severe thrombocytopenia was observed in both patients following the second rituximab infusion. In addition, mild leukopenia, hypocomplementemia, and systemic inflammation were observed. Most previous reports have described RIAT in patients with hematological malignancies, but patients with autoimmune diseases may also develop this condition.

Atrial fibrillation (AF) after bioprosthetic valve (BPV) replacement is common in older patients with multiple comorbidities and is associated with a heightened risk of thromboembolism. Anticoagulation therapy is often indicated, but renal impairment and other comorbidities elevate bleeding risk, making clinical decisions complex. This study compared clinical outcomes between warfarin and direct oral anticoagulants (DOACs) in this high-risk population. This subgroup analysis of the BPV-AF Registry included 612 patients treated with oral anticoagulants after BPV replacement, stratified by renal function: normal or mild impairment (creatinine clearance [CCr] ≥50 mL/min), mild-to-moderate impairment (30 mL/min ≤ CCr < 50 mL/min), and moderate-to-severe impairment (15 mL/min ≤ CCr < 30 mL/min). Baseline characteristics and outcomes were analyzed within each stratum. The composite outcome of stroke, systemic embolism, and cardiovascular events was numerically less frequent in the DOAC than warfarin group across all strata, although the differences were not statistically significant. Major bleeding also tended to be lower in the DOAC group. In this study from a Japanese nationwide registry comparing outcomes of AF patients after BPV replacement with severe renal impairment between those treated with DOACs and those treated with warfarin, comparative conclusions between DOACs and warfarin cannot be drawn because of the small sample size. Nonetheless, both anticoagulants may be acceptable in clinical practice, highlighting the need for individualized decision-making based on patient risk.

IgG4関連疾患はIgG4を発現する形質細胞が関与し，全身の諸臓器に腫瘤や肥厚形成を来す疾患である．今回，我々は肺癌との鑑別を要したIgG4関連肺疾患の1例を経験したので報告する．

Background: Periarterial echogenicity in the proximal coronary arteries is known to increase in the acute phase of Kawasaki disease (KD). However, some studies have questioned its clinical value given its relatively low specificity. In this study, we quantitatively assessed the brightness in the proximal and mid portion of both coronaries to find its additional diagnostic value in patients with clinically suspected KD. Methods: We retrospectively analyzed 109 consecutive children (median age 21 months [IQR 11.0–47.8]) who underwent transthoracic echocardiography for suspected KD between April 2021 and March 2023. Two-dimensional echocardiographic images of the proximal and mid segments of both coronary arteries were digitally stored and analyzed offline (Image 1). Mean pixel intensity of the arterial walls was measured in grayscale (0–255). The intracardiac blood pool adjacent to the target site was measured as a reference background value, and the difference was recorded as the brightness value (Image 2). Results and Discussions: Among the 109 patients, 87 (80%) were diagnosed with KD (including 18 with incomplete KD), while 22 were diagnosed with other febrile illnesses (non-KD group) such as virus infections or bacterial infections. There were no significant differences in age, or body size, the duration of fever at the time of the echocardiographic examination and CRP concentrations between the two groups. While the KD group exhibited higher brightness than the febrile group, there were no significant differences in the mean pixel values (proximal right coronary artery; 148 vs. 161, p=0.34; left main coronary artery;129 vs. 116, p=0.34, respectively) (Image 3). Whereas, the KD group exhibited significantly higher brightness in the mid-segment (mid right coronary artery; 139 vs. 121, p=0.0049, mid left anterior descending artery; 136 vs. 111, p=0.011, respectively). Our results might reflect the pathophysiological characteristics of coronary vasculitis in KD that simultaneously and diffusely involve the coronary territories from the proximal to distal branches. Conclusions: Echogenicity of the mid-segment of the coronary arteries would have a diagnostic impact in the initial diagnosis of KD. Therefore, examining not only the proximal segment, but also up to the mid-segment, of the coronary arteries may be useful for differentiating KD.

BackgroundWe reported psychiatric comorbidity (1375/1900, 72.4%) in patients with dizziness.Aims & ObjectivesIn this study, we investigated about tinnitus or auditory hallucination.MethodThe subjects were 413 patients (167men, 246 women) with tinnitus and 39 patients (13 men, 26 women) with auditory hallucination. Psychiatric comorbidity was revealed in 77.5% (320/413) with tinnitus and in 97.4% (38/39) with auditory hallucination. AhHI (Auditory hallucination Handicup Inventory), which is a revised version of THI, was used as an evaluation method for auditory hallucinations. We reported psychiatric comorbidity (1375/1900, 72.4%) in patients with dizziness. In this study, we investigated about tinnitus or auditory hallucination.ResultsAn evaluation of sleep disorders was effective using Insomnia Severity Index (ISI). Sound therapy was performed on 52 cases of tinnitus and 6 cases of auditory hallucinations. With sound therapy, Case 1 improved from THI 100 to 2 points and AhHI 98 to 0 points, and Case 2 improved from THI 32 to 0 points and AhHI 66 to 0 points.A 36-year-old woman (Case 3) with schizophrenia, whose main complaints were dizziness, tinnitus, and auditory hallucinations, had a THI of 86 points, AhHI of 76 points, DHI of 96 points, and ISI of 24 points. With psychiatric treatment her score improved to THI 42 points, AhHI 20 points, DHI 58 points, and ISI 11 points. The 77-year-old man (Case 4) with right paraocular auditory hallucinations did not have psychiatric comorbidity. An evaluation of sleep disorders was effective using Insomnia Severity Index (ISI). Sound therapy was performed on 52 cases of tinnitus and 6 cases of auditory hallucinations. As a treatment for auditory hallucination, sound therapy, oral antipsychotic drug and long-acting injection (LAI) were effective. Shared Decision Making (SDM) was performed to increase treatment continuation rates.Discussion & ConclusionsWe believe that neuro-otological evaluation and sleep evaluation are useful for treating tinnitus or auditory hallucinations, and that improving insomnia, reducing anxiety, sound therapy and SDM are also useful.

ObjectiveTo determine the prevalence of abnormal scar formation after cesarean section and evaluate its effects on quality of life (QoL) and postpartum depression risk.MethodsA nationwide cross‐sectional study of 991 women aged 18–45 years at 6–18 months post‐cesarean section was conducted in Japan. Participants completed validated measures of scar assessment (Dermatology Life Quality Index [DLQI]) and postpartum depression risk (Edinburgh Postnatal Depression Scale [EPDS]).ResultsAmong participants, 66.0% Abnormal scarring has been reported to occur more frequently in Asian and Black populations than in White populations, consistent with previous epidemiological studies. (654/991) developed abnormal scars (64.4% hypertrophic, 1.6% keloid). The abnormal scar group showed significantly higher DLQI scores, indicating worse QoL (median 1, interquartile range 0–2 vs median 0, interquartile range 0–1; P < 0.001). Women with keloid formation showed elevated EPDS scores, indicating higher depression risk.ConclusionAbnormal scar formation is highly prevalent, abnormal scars impair maternal quality of life, and keloid formation is linked to an increased risk of postpartum depression.

Chemotherapy-induced neutropenia has been identified as a potential prognostic marker for multiple cancers. However, only one retrospective study, NN-2301, has investigated the relationship between neutropenia and treatment effects of nanoliposomal irinotecan/5-fluorouracil/folinic acid (NFF) in pancreatic cancer. In this prospective study, we aimed to clarify whether NFF-induced neutropenia could serve as a prognostic marker in pancreatic cancer. Data were analyzed from the prospective cohort of the NAPOLEON-2 trial, an observational study involving patients with unresectable pancreatic cancer treated with NFF. Neutropenia severity was categorized into three cutoffs: Cutoff A (Grade [Gr] 0 vs. Gr 1-4), cutoff B (Gr 0-1 vs. Gr 2-4), and Cutoff C (Gr 0-2 vs. Gr 3-4), using the Common Terminology Criteria for Adverse Events version 5.0, owing to conformity with previous studies and simplicity. The primary endpoint was overall survival (OS); progression-free survival (PFS) was the secondary endpoint. The neutropenic groups included Gr 1, 2, 3, and 4, with 79, 23, 34, and 7 patients, respectively. At each cutoff, OS and PFS were significantly better in the severe neutropenia groups. Higher neutropenia grades correlated with improved OS (log-rank trend test: χ2 = 8.62, p < .01). Multivariate Cox regression analysis revealed significant differences for all cutoffs: adjusted hazard ratios were 0.57 (95% confidence interval [CI] 0.40-0.83) (Cutoff A), 0.53 (95% CI 0.36-0.78) (Cutoff B), and 0.52 (95% CI 0.34-0.80) (Cutoff C). NFF-induced neutropenia is a valuable prognostic marker in pancreatic cancer and may guide treatment selection.

Adult T-cell leukemia/lymphoma (ATL) is a peripheral T-cell malignancy with a poor prognosis. We conducted a retrospective study across six institutions in Miyazaki Prefecture, Japan, to assess the efficacy of tucidinostat in patients with relapsed/refractory ATL who had not undergone transplantation. Between October 2021 and July 2023, 24 patients aged 41 to 88 years (median, 73.4 years) who had undergone prior therapies, including intensive chemotherapy (79.2%) and mogamulizumab immunotherapy (79.2%), received tucidinostat. Objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS) were evaluated as key outcomes. ORR and DCR reached 54.2% and 91.7%, respectively. The median PFS was 3.95 months, and OS was 8.04 months, which were not inferior to the results of a phase IIb study. The influential factors for PFS were age ≥ 75 years and high soluble IL-2 receptor (sIL-2R) levels above 5000 U/mL at the start of treatment. Favorable patients without these factors achieved a PFS of 11.4 months. Treatment-related adverse events were mainly hematologic but were managed over the course of treatment. Our findings indicate that tucidinostat provides survival benefits in patients with relapsed/refractory ATL in clinical practice and highlight key clinical factors for better outcomes.

ABSTRACTIntroductionMinimally invasive surgery for congenital biliary dilatation (MICBD), including both laparoscopic and robotic approaches, is gaining increasing popularity. However, the evidence remains limited, especially across both adult and pediatric populations.MethodsConsensus statements on MICBD were formulated during a multidisciplinary consensus meeting, addressing two clinical questions focused on the use of MICBD in Todani classification types I and IV‐A. A comprehensive literature review and expert survey were performed. Consensus was achieved through a Delphi voting process, with statements approved when ≥ 75% agreement was reached.ResultsThe literature review revealed that although MICBD was associated with prolonged operative times, the approach resulted in reduced blood loss and shorter hospital stays, with complication rates comparable to those observed in open surgery. In the expert survey, MICBD was supported by 81% of respondents for type I and 64% for type IV‐A. The following consensus statement was developed: “MICBD for both Todani classification type I and type IV‐A can be considered; however, it is preferable for the procedure to be performed by a team experience in minimally invasive surgery.” This statement achieved unanimous agreement in the Delphi vote.ConclusionDue to a lack of high‐level evidence, formal recommendations for MICBD remain premature. Expert consensus supports MICBD for both types I and IV‐A cases, provided that the procedures are performed by experienced surgical teams. Further high‐quality studies and long‐term outcome assessments are essential to establish safety and efficacy.