A single‐sided trans‐nasal catheter for smooth and efficient oxygen delivery can improve the safety in patients undergoing pancreato‐biliary endoscopy under intravenous sedation: A randomized trial

Background

Pancreato‐biliary endoscopic procedures often need to be performed under deep intravenous sedation. The patients are at an increased risk of respiratory depression influenced by the anatomical dead space of the upper respiratory system. We aimed to evaluate the benefit of oxygen delivery through a single‐sided trans‐nasal catheter (TC) for patients undergoing pancreato‐biliary endoscopy.

Methods

Oxygen supplementation during the procedure was provided either by insertion of a single‐sided TC or insertion of a conventional nasal catheter (NC). A prospective, single‐blind, randomized controlled study was conducted in two groups.

Results

The number of patients who indicated a decrease in the peripheral transcutaneous oxygen saturation (SpO2; desaturation) was significantly lower in the TC group than in the counterpart (8/58; 13.8% vs. 26/58; 44.8% p < 0.001). The efficient oxygen delivery in the safe range was better conserved in the TC group than in the NC one. There was no adverse effect on both groups. The maximum SpO2 while the endoscopic procedure was significantly higher in the TC group (99.7% vs. 99.3% p = 0.016) and the minimum SpO2 was also significantly higher in the same group (97.7% vs. 94.1% p < 0.0001), which meant that the efficient oxygen delivery was better maintained in TC group than the NC group.

Conclusions

A single‐sided TC placed in the pharynx in patients undergoing pancreato‐biliary endoscopy prepares a superior condition of the patients for venous sedation, maintained hyper‐oxygen saturation and a relatively higher SpO2 level to be maintained in limited conditions to reduce the dead space with acceptable tolerance, as compared to the placement of a conventional NC.

Brain Hypothermia Therapy and Targeted Temperature Management for Acute Encephalopathy in Children: Status and Prospects

In adult intensive care, brain hypothermia therapy (BHT) was reported to be effective in neuroprotection after resuscitation and cardiac arrest. By contrast, in neonatal intensive care, the pathophysiology of brain damage caused by hypoxic–ischemic encephalopathy (HIE) is attributed to circulatory disturbances resulting from ischemia/reperfusion, for which neonatal brain cryotherapy is used. The International Liaison Committee on Resuscitation, 2010, recommends cerebral cryotherapy for HIE associated with severe neonatal pseudoparenchyma death. The usefulness of BHT for neuroprotection in infants and children, especially in pediatric acute encephalopathy, is expected. Theoretically, BHT could be useful in basic medical science and animal experiments. However, there are limitations in clinical planning for treating pediatric acute encephalopathy. No international collaborative study has been conducted, and no clinical evidence exists for neuroprotection using BHT. In this review, we will discuss the pathogenesis of neuronal damage in hypoxic and hypoperfused brains; the history of BHT, its effects, and mechanisms of action; the success of BHT; cooling and monitoring methods of BHT; adverse reactions to BHT; literature on BHT. We will review the latest literature on targeted temperature management, which is used for maintaining and controlling body temperature in adults in intensive care. Finally, we will discuss the development of BHT and targeted temperature management as treatments for pediatric acute encephalopathy.

Intravenous tocilizumab for Takayasu arteritis with aortic aneurysms, bilateral renal artery stenosis, and atypical aortic coarctation in a 2-year-old girl

Takayasu arteritis (TAK) is classified as large vessel vasculitis, and continuous inflammation of the vessel results in aneurysm or stenosis, which leads to various serious complications. Recently, a TAKT [TAK treated with tocilizumab (TCZ)] study showed that subcutaneous TCZ, a humanised anti-interleukin-6 receptor monoclonal antibody, is an effective treatment in patients with TAK above 12 years of age; however, the effectiveness of TCZ for juvenile TAK under 12 years old remains unclear. Here, we described the case of a 2-year-old girl with TAK, which was successfully treated with intravenous TCZ. She was diagnosed with TAK type V (Numano's angiographic classification system) with aortic aneurysms, bilateral renal arteries stenosis, and atypical descending aortic coarctation based on contrast-enhanced computed tomography findings. Treatment was started with 2 mg/kg/day prednisolone (PSL) and methotrexate instead of methylprednisolone pulse due to renovascular hypertension. She was immediately afebrile and her C-reactive protein level decreased, although it was elevated 4 weeks after starting PSL. Intravenous TCZ of 8 mg/kg/2 weeks was added because the progression of aneurysms or stenosis might lead to a poor prognosis. PSL was steadily reduced under intravenous TCZ. Magnetic resonance imaging showed that aortic aneurysms, renal arteries stenosis, and aortic coarctation ameliorated 4 months after starting TCZ, with the amelioration maintained at 1 year after starting TCZ. Aneurysms and stenosis improved; therefore, TCZ may be effective for the treatment of inflammation of vessels, aneurysms, and stenosis. It is desirable to examine the effect of TCZ on TAK patients under 12 years of age.

[A Case of Giant Abdominal Desmoid Tumor in a Young Man]

Desmoid tumor is a rare tumor of the soft tissue. The frequency of occurrence is 2.4 to 4.3 cases per year per million people, which is a very rare disease. We experienced a huge intra-abdominal desmoid tumor which is thought to be the primary mesentery. The case was a male in his 20s. He visited a nearby doctor with a complaint of abdominal bloating and abdominal pain. Abdominal contrast CT revealed a huge abdominal mass with a clear boundary of 35×25 cm in size extending from the upper right abdomen to the pelvis. Surgery was performed with a diagnosis of an intra-abdominal mass. Open abdominal tumor resection. Due to infiltration into the duodenum, transverse colon, and pancreas, right hemicolectomy and duodenal combined resection were performed. The pathological diagnosis was a diagnosis of desmoid tumor.

Food protein-induced enterocolitis syndrome due to buckwheat: A case report

Buckwheat is a rare causative food for food protein-induced enterocolitis syndrome (FPIES). To date, it is unknown what laboratory data patients with FPIES caused by buckwheat show. We report a 4-year-old female with FPIES caused by buckwheat and the laboratory results. Skin prick, specific IgE antibody, and basophil activation tests were negative; however, the lymphocyte stimulation test (LST) revealed a 10.2-fold increase in activation compared with the negative control. In an open-label oral food challenge (OFC) of 80 g boiled buckwheat noodles, 3 hours after ingestion, vomiting occurred four times in a 2-hour duration. Therefore, we diagnosed the patient with FPIES caused by buckwheat. Her neutrophil count, C-reactive protein, and thymus and activation-regulated chemokine were elevated after the OFC. Moreover, the patient had a positive reaction to the LST, which may theoretically be useful in diagnosing non-immunoglobulin E-mediated gastrointestinal food allergies. FPIES caused by buckwheat is rare; however, we found that the same laboratory results were observed in a comparison of FPIES cases caused by other foods.

Pollen Food Allergy Syndrome in Japanese Children and Adolescents: Risk Factors and Pollen Sensitisation

Pollen food allergy syndrome (PFAS) is caused by cross-reactivity with pollen; however, not all-pollen-sensitised individuals develop PFAS, and studies on the characteristics of PFAS development are limited in Japan. We investigated the prevalence and risk factors for the development of PFAS in Japanese children and adolescents sensitised to pollen and their association with pollen-specific IgE levels. The characteristics of PFAS were investigated in patients with allergies aged 3-18 years who visited Dokkyo Medical University Hospital between January 2016 and December 2019. Specific IgE levels for alder, Japanese cedar, ragweed, and orchard grass were measured in patients sensitised to any of the pollens. Patients were categorised into preschool (G1), elementary school (G2), and middle-high school (G3) groups. Overall, 600 patients were enrolled. The prevalence of PFAS was 8.5% in G1, 20% in G2, and 36.3% in G3. Multivariate logistic regression analysis demonstrated strong associations between the risk of developing PFAS and older age (odds ratio (OR), 1.12; 95% confidence interval (CI), 1.06-1.19; P < 0.001), seasonal allergy rhinitis (OR, 6.93; 95% CI, 1.59-30.34; P = 0.010), and alder sensitisation (OR, 6.20; 95% CI, 2.66-14.49; P < 0.001). Spearman's correlation revealed statistically significant positive correlation between each pollen-specific IgE level; high pollen-specific IgE levels were also a risk factor. The OR for being sensitised to all four species was 36.83 (95% CI, 8.93-151.83, P < 0.001) when compared with Japanese cedar alone. Alder was most relevant, with an alder-specific IgE level cutoff value of 2.54 UA/mL. The sensitivity was 78.9%, and the specificity was 70.9%. In conclusion, preschool children develop PFAS with alder sensitisation, and higher pollen-specific IgE levels and increased number of pollen sensitisations are risk factors for developing PFAS.

[A Case of Primary Hepatic Mucosa-Associated Lymphoid Tissue Lymphoma]

A 74-year-old man with no chronic liver disease was admitted for an incidental liver tumor by computed tomography. Serological examinations for hepatitis B and C virus were negative and tumor markers, including carcinoembryonic antigen, α-fetoprotein, carbohydrate antigen 19-9, and des-gamma-carboxy prothrombin, were within the normal range. The contrast- enhanced magnetic resonance imaging revealed that the 26 mm in diameter patchy tumor occupied the S7 in the liver. The tumor boundary was enhanced slightly in the arterial phase and inside gradually in the portal phase, and the enhancement was faded in the late phase. As a characteristic finding, vessels penetrated the tumor. The tumor was diagnosed as cholangiocarcinoma, and the patient underwent right lateral sectionectomy. After 19 days postoperatively, the patient was discharged. The diagnosis of hepatic mucosa-associated lymphoid tissue(MALT)lymphoma was made by pathological examination. Currently, the patient has no recurrence for 5 months without adjuvant chemotherapy. The primary hepatic MALT lymphoma is a rare disease among primary hepatic malignant lymphomas. The patient must be followed up carefully because 2 cases were reported as recurrent cases after several years postoperatively although the disease has a good prognosis.

[A Case of Giant Pancreatic Mucinous Cystic Neoplasm That Was Difficult to Preoperative Diagnosis]

A 43-year-old woman with about abdominal distension was referred to our hospital for a more detailed examination. Abdominal CT showed 27 cm-sized cystic lesion with the calcification along the partition wall and a nodular hyperplasia. We suspected pancreatic pseudocyst, primary retroperitoneal tumor and we performed tumorectomy. The resected specimen had a maximum diameter of 27 cm. The histopathological diagnosis was mucinous cystadenocarcinoma of the pancreas with ovarian-type stroma. The adjuvant chemotherapy treated with gemcitabine was selected for 3 courses. She continues to do well without any recurrences 7 months later.

[A Case of Laparoscopically Resected Sigmoid Colon Cancer and Transverse Colon Mesentery Primary Solitary Fibrous Tumor]

The patient is a 52-year-old woman who visited the general practitioner because of positive fecal occult blood test by medical examination. The patient underwent colonoscopy at the hospital, which revealed sigmoid colon cancer. Therefore, the patient was referred to our hospital for surgery. Preoperative CT scan revealed a well-defined and lobulated 54 mm tumor on the caudal side of the duodenal third portion. On MRI, the tumor showed low T1-weighted image signal and high T2-weighted and diffusion-weighted images signal, with low ADC. For preoperative diagnosis, we diagnosed sigmoid colon cancer and transverse colon mesenteric and performed laparoscopic sigmoid colon and transverse colon mesenteric tumor resections. The histopathological tumor diagnoses were sigmoid colon cancer(S, type 2, 30×30 mm, 1/2 circumference, moderately differentiated adenocarcinoma, pT3[SS], INF b, Ly1a, V1a, pN1b[#252: 2/4], sM0, fStage Ⅲb)and transverse colon mesentery primary solitary fibrous tumor. The patient was treated with XELOX as the adjuvant chemotherapy and survived without recurrence until present.

A Rare Case of Paratesticular Cystadenoma with Ovarian Stroma Found by Scrotal Ultrasound on a Cirrhotic Patient with Elevated Alpha-fetoprotein

Introduction/Objective

Paratesticular cystadenoma with ovarian stroma is a rare benign cyst-forming neoplasm with less than 10 cases reported in the literature. Typically, it presents in men aged 11 to 68 years (average 30) and is asymptomatic. The tumor is hypothesized to represent the efferent ductulus undergoing metaplastic change, the vestigial remnants of Mullerian duct, or mesothelium of the tunica vaginalis. Most tumors are considered benign, but a few cases of malignant transformation have been reported.

Methods/Case Report

We present a case of a 54-year-old male with a history of cirrhosis and elevated alpha-fetoprotein (17.85 ng/ML) who was found to have a paratesticular mass by scrotal ultrasound. Clinical history was obtained from review of electronic medical record. CD10 (Novocastra Clone 56C6) and progesterone receptor (PR) (Leica Clone 16) Immunoperoxidase stains were performed following the vendor recommendations. Surgical excision revealed a 0.6-cm polypoid nodule on tunica albuginea that was entirely submitted. Microscopically, the tumor was comprised of cystic spaces lined by cuboidal epithelium identical to that of the Fallopian tubes. There was a sparse spindle-shaped stroma underlying the epithelium similar to ovarian stroma. No nuclear atypia or mitosis was found. Immunoperoxidase stains showed the epithelium was positive for PR, and the stroma was positive for CD10. No evidence of germ cell tumor was identified.

Results (if a Case Study enter NA)

NA.

Conclusion

Characteristic histologic and immunophenotypic findings can aid in the diagnosis of paratesticular cystadenoma with ovarian stroma. Surgical resection for histological confirmation and long-term monitoring for the potential recurrence and metastatic spread are required.

Synthesis and Preliminary Evaluation of an 18F-labeled Oleate Analog to Image Fatty Acid Beta-Oxidation in the Absence of Metabolic Defluorination

PURPOSE

Fatty acid oxidation (FAO) is a key parameter for evaluating cardiovascular, oncologic, neurologic, and other metabolic diseases. Several single-photon emission computed tomography and positron emission tomography (PET) tracers have been developed to measure FAO. Among these, 18-[¹⁸F]fluoro-4-thia-oleate ([¹⁸F]FTO), first developed by DeGrado et al., is well characterized. Here, we synthesized several analogs of [¹⁸F]FTO to improve the metabolic stability of the C-¹⁸F bond, and preliminarily evaluated their performance in monkey PET studies.

PROCEDURES

Several secondary ¹⁸F-fluorinated analogs, 17-[¹⁸F]fluoro-4-thia-oleate (17-[¹⁸F]FTO), 15-[¹⁸F]fluoro-4-thia-oleate (15-[¹⁸F]FTO), 12-[¹⁸F]fluoro-4-thia-oleate (12-[¹⁸F]FTO), 7-[¹⁸F]fluoro-4-thia-oleate, (7-[¹⁸F]FTO, [¹⁸F]AS3504073-00), and 6-[¹⁸F]fluoro-4-thia-oleate (6-[¹⁸F]FTO), were synthesized from tosylate or bromide precursors using similar procedures. Nucleophilic ¹⁸F fluorination on each precursor was performed using [¹⁸F]tetrabutylammonium fluoride/tetrabutylammonium hydrocarbonate, followed by hydrolysis of methylester. All synthesized ¹⁸F-labeled compounds were administered to cynomolgus monkeys, and PET measurements were performed. From the monkey PET studies, 7-[¹⁸F]FTO was selected as the best tracer and used to perform preliminary evaluations in mice.

RESULTS

All five compounds had sufficient quality and stability for animal experiments. In monkey PET studies, 12-, 7-, and 6-[¹⁸F]FTO showed greater accumulation in the heart than [¹⁸F]FTO, but not 17- and 15-[¹⁸F]FTO. Only 7-[¹⁸F]FTO did not show significant accumulation in the bone. The standardized uptake values (SUVs) for 12-[¹⁸F]FTO, 7-[¹⁸F]FTO, and 6-[¹⁸F]FTO were 9.77, 9.26, and 7.25 in the heart, and 3.17, n.d., and 1.96 in the bone 1 h after administration, respectively. In mouse distribution studies, SUVs 1 h after administration of 7-[¹⁸F]FTO and [¹⁸F]FTO were 10.4 and 10.0 in the heart, and 0.37 and 3.48 in the femur, respectively. Administration of etomoxir, a carnitine palmitoyltransferase inhibitor, reduced SUVs of 7-[¹⁸F]FTO and [¹⁸F]FTO in the heart by 91% and 87%, respectively.

CONCLUSIONS

We developed a novel PET tracer 7-[¹⁸F]FTO/[¹⁸F]AS3504073-00 for FAO imaging. 7-[¹⁸F]FTO had an excellent PET tracer profile, suggesting it may be a useful tracer for FAO imaging. Further evaluations of the tracer are ongoing.

Update of the fracture risk prediction tool FRAX: a systematic review of potential cohorts and analysis plan

We describe the collection of cohorts together with the analysis plan for an update of the fracture risk prediction tool FRAX with respect to current and novel risk factors. The resource comprises 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures.

INTRODUCTION

The availability of the fracture risk assessment tool FRAX® has substantially enhanced the targeting of treatment to those at high risk of fracture with FRAX now incorporated into more than 100 clinical osteoporosis guidelines worldwide. The aim of this study is to determine whether the current algorithms can be further optimised with respect to current and novel risk factors.

METHODS

A computerised literature search was performed in PubMed from inception until May 17, 2019, to identify eligible cohorts for updating the FRAX coefficients. Additionally, we searched the abstracts of conference proceedings of the American Society for Bone and Mineral Research, European Calcified Tissue Society and World Congress of Osteoporosis. Prospective cohort studies with data on baseline clinical risk factors and incident fractures were eligible.

RESULTS

Of the 836 records retrieved, 53 were selected for full-text assessment after screening on title and abstract. Twelve cohorts were deemed eligible and of these, 4 novel cohorts were identified. These cohorts, together with 60 previously identified cohorts, will provide the resource for constructing an updated version of FRAX comprising 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures. For each known and candidate risk factor, multivariate hazard functions for hip fracture, major osteoporotic fracture and death will be tested using extended Poisson regression. Sex- and/or ethnicity-specific differences in the weights of the risk factors will be investigated. After meta-analyses of the cohort-specific beta coefficients for each risk factor, models comprising 10-year probability of hip and major osteoporotic fracture, with or without femoral neck bone mineral density, will be computed.

CONCLUSIONS

These assembled cohorts and described models will provide the framework for an updated FRAX tool enabling enhanced assessment of fracture risk (PROSPERO (CRD42021227266)).

Magnetic resonance imaging of a pediatric case of arthritis associated with acute lymphoblastic leukemia: A case report

In the present case report, a 3-year-old girl presented with a 1-week history of spontaneously resolving right knee pain. After 1 month, the patient had trouble ambulating due to painful swelling of their ankle. Rheumatic disease, specifically juvenile idiopathic arthritis, was considered. Blood examination could not be conducted because their blood sample was coagulated. T₁-weighted magnetic resonance imaging (MRI) revealed abnormally low signals in the femur, tibia, fibula and foot bone marrow. Contrast-enhanced T₁-weighted MRI revealed synovial contrast enhancement and synovial fluid retention in the right ankle joint. Blood analysis revealed a white blood cell count of 40,000/µl (blasts, 66%). In addition, a monoclonal increase in the number of lymphoblasts was observed. The patient was subsequently diagnosed with B-cell precursor acute lymphoblastic leukemia. Reports on leukemic arthritis resembling synovitis on MRI remain limited. The findings of this report indicated that pediatricians should consider leukemia in children presenting with joint symptoms.

Multiple encephalopathy syndrome: a case of a novel radiological subtype of acute encephalopathy in childhood

INTRODUCTION

This report presents the case of a novel subtype of acute encephalopathy syndrome in childhood found in a patient with influenza type A infection; the patient exhibited evident magnetic resonance imaging (MRI) findings.

CASE REPORT

A 4-year-old boy was transferred to our hospital for prolonged (lasting 60 min) status epilepticus with influenza encephalopathy. Mild brain hypothermia therapy was applied for 72 h, followed by targeted temperature management for 96 h with mechanical ventilation in the intensive care unit. Moreover, methylprednisolone pulse therapy and immunoglobulin therapy were administered. One month after the treatment, his physical status recovered such that he was able to run, take food orally, communicate verbally, and successfully return to kindergarten. Interestingly, serial MRI studies revealed findings that were compatible with 1) acute necrotizing encephalopathy (ANE), 2) mild encephalitis/encephalopathy with a reversible splenial lesion (MERS type II), 3) acute cerebellitis, and 4) acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) on days 2, 4, 7, and 16, respectively.

CONCLUSIONS

To the best of our knowledge, these significant MRI findings associated with acute encephalopathy have never been reported. Thus, herein, we propose the new term radiological "multiple encephalopathy syndrome (MES)" based on our case of acute encephalopathy in childhood.