Objective Endoscopic gallbladder stenting (EGBS) is an alternative treatment option for high-risk surgical patients with acute cholecystitis. However, there are no reports focusing on EGBS in patients with concomitant unresectable cancer. The aim of this study was thus to evaluate EGBS in such patients. Methods Twenty-two consecutive patients with acute cholecystitis and unresectable cancer were enrolled between September 2010 and December 2014. Their median age was 74.5 years (range: 51-95). Thirteen patients were men and nine were women. The primary cancers of the patients were biliary tract cancer (9), pancreas cancer (9), lung cancer (2), gastric cancer (1), and colon cancer (1). The causes of cholecystitis were calculus cholecystitis (7), obstruction by malignant tumor (13), and obstruction by fully covered stent (2). Results EGBS was successfully performed in 17 patients (77.2%). The technical success rates for calculus cholecystitis, obstruction by malignant tumor, and obstruction by fully covered stent were 85.7% (6/7), 69.2% (9/13), and 100% (2/2), respectively. No complications were observed. Percutaneous transhepatic gallbladder drainage was conducted on two patients in whom EGBS had failed and then we performed EGBS by a rendezvous approach. Of the 19 patients in whom we finally deployed EGBS, the median follow-up period was 229 days (range: 14-880 days). A recurrence of acute cholecystitis occurred in three (15.7%) patients 14, 130, and 440 days after EGBS placement. The rates of recurrence of cholecystitis at one and two years were 10.5% and 18.7%, respectively. Conclusion Our study demonstrated that EGBS is a safe and effective method for acute cholecystitis in patients with concomitant unresectable cancer.

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Objective To examine the association between glycemic control and the new onset of macroangiopathy in Japanese subjects with type 2 diabetes. Methods We examined seven-year follow-up data for 572 patients. We divided the subjects by the average of seven-year glycemic control based on the guidelines. First, we excluded the subjects with a past history of macroangiopathy and then examined the incidence of the new onset of macroangiopathy. Results The incidence of ischemic heart disease (IHD) was 1.0% per year, and that of cerebral vascular disease (CVD) was 1.0% per year. However, IHD events were not observed at all for five years in the most intensive glycemic control group (HbA1c<6%). Similarly, CVD events were not observed at all for seven years in the most intensive glycemic control group (HbA1c<6%). In addition, the cumulative incidence rate of IHD tended to increase as the glycemic control became poorer (HbA1c<6%, 4.5%; 6%≤HbA1c<7%, 6.0%; 7%≤HbA1c<8%, 7.2%; HbA1c≥8%, 10.7%). Furthermore, a logistic regression analysis showed that the duration of diabetes and HbA1c level were independent risk factors contributing to the onset of IHD, but not to the onset of CVD. Conclusion This seven-year observational study showed the possible association between glycemic control and the onset of macroangiopathy in a total of 572 Japanese subjects with type 2 diabetes.

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Objective We investigated the relationship of the waist circumference (WC) and body fat weight (BF) with insulin resistance in subjects with normal body mass index (BMI) and normal glucose tolerance (NGT) during a routine medical check-up. Methods We categorized 167 male subjects in three groups as follows: a group with normal BMI but high WC (normal-BMI/high-WC group; 22≤BMI<25 kg/m², waist ≥85 cm; n=31), a group with normal BMI and normal WC (normal-BMI/normal-WC group, waist <85 cm; n=68), and a group with low normal BMI and normal WC (low normal-BMI/normal-WC group; 18.5≤BMI<22 kg/m² and waist<85 cm; n=68). We measured the plasma glucose and serum insulin levels before glucose loading and after 30 and 120 minutes and calculated several indexes of insulin secretion and sensitivity. Results Subjects from the normal-BMI/high-WC group showed significantly decreased Matsuda index and increased homeostasis model assessment for insulin resistance (HOMA-IR) compared with normal-BMI/normal-WC group. Univariate regression analyses showed significant correlation of HOMA-IR with WC (r=0.39) and BF (r=0.37). Matsuda index was significantly correlated with WC (r=-0.39) and BF (r=-0.47). The multiple regression analysis showed that the BF is significantly correlated with HOMA-IR (p<0.05) and Masuda index (p<0.005) among the clinical variables and with HOMA-IR (p<0.05) and Masuda index (p<0.0001) among the anthropometric variables but not with WC in either analysis. Conclusion Decreased Matsuda index and increased HOMA-IR were observed in subjects from the normal-BMI/high-WC group. Multivariate analysis showed that BF is associated with decreased Matsuda index and increased HOMA-IR and that WC is not associated with either factors.

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Objective There are many adverse reactions due to clindamycin, but kidney diseases (acute kidney injury, AKI) are uncommon. However, in recent years, the rate of clindamycin-induced kidney diseases has increased. We analyzed 50 patients with clindamycin-induced kidney diseases retrospectively, and investigated the characteristics of these kidney diseases in order to provide a reference for rational clinical drug use and to reduce drug-induced organ damage. Methods We investigated 50 patients diagnosed with clindamycin-induced kidney diseases retrospectively at the Department of Nephrology, Shandong University Qilu Hospital, from January 2009 to December 2013. The parameters included in our study were age, sex, clinical manifestations, efficacy and prognosis. Results All patients were diagnosed with clindamycin-induced kidney diseases within 48 hours of the application of clindamycin at 1.0-2.0 g/day. The patients included 29 women and 21 men. Most of the enrolled patients were 20-59 years old. Fifty-one patients were diagnosed with AKI stage 3 upon admission. Thirty-three had episodes of gross hematuria, but fever, skin rash and eosinophilia were rare. Urine analysis revealed mild proteinuria and severe tubular dysfunction. In the majority of patients, AKI was severe and required renal replacement therapy, but renal function in all patients had recovered significantly two months after discharge. Conclusion Clindamycin-induced AKI is largely reversible and is associated with episodes of gross hematuria. Clinicians should use clindamycin rationally and reduce the incidence of adverse reactions.

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Objective We elucidated the effectiveness of a humanized CCR4 antibody (mogamulizumab) on adult T-cell leukemia-lymphoma (ATL), which typically has a poor outcome. Methods We retrospectively analyzed 14 patients with aggressive ATL who had been treated at our institution with weekly cycles of mogamulizumab for eight weeks from 2012-2014. Results The patients (median age: 63 years old) were classified as having acute- (n=10) or lymphoma-type (n=4) ATL. The prior treatment regimens consisted of CHOP, VCAP-AMP-VECP, DeVIC and CHASE, with an average of two courses (range: 1-4). The prior disease responses were partial remission (n=3) and progressive disease (n=11). The treatment was administered in the primary refractory setting (n=8), for relapse (n=2), or as bridging therapy before hematopoietic stem cell transplantation (n=4). The overall response rates were 64% and 43% after four and eight cycles (or after the final cycles), respectively. The median overall survival (OS), OS rate at six months and OS rate at 12 months were 66 days, 41.7% and 20.8%, respectively. All of the patients with acute-type ATL who showed a response to treatment had an early response. Notably, six of the 14 ATL patients showed somewhat prolonged survival (>100 days). However, relapse or disease progression in the peripheral blood, central nervous system, lymph nodes, skin, and/or bone occurred within a relatively short period after treatment. The adverse effects were tolerable, and included lymphopenia, cytomegalovirus infection and skin rash. Conclusion Mogamulizumab therapy resulted in an early and high remission rate and somewhat prolonged survival in patients with refractory ATL. However, the duration of remission was short, and there was early relapse and disease progression. This study may show the current impact of mogamulizumab in clinical practice.

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Objective Left atrial enlargement (LAE) may predispose individuals to blood stasis in atrial fibrillation (AF), and thus play a crucial role in thrombogenesis. The D-dimer level is one of the surrogate markers for a hypercoagulable state and reflects thrombus formation in AF. Since the D-dimer level reflects hypercoagulability as well as thrombus and fibrin burdens, LAE could be associated with a D-dimer elevation. However, no studies have explored this association or which factors contribute to increases in the D-dimer levels in patients with AF. Therefore, we assessed whether the serum D-dimer levels are related to the left atrial volume index (LAVI) or other vascular risk factors and also evaluated the association between the D-dimer levels and the initial stroke severity. Methods Ninety-eight consecutive patients with an acute ischemic stroke and non-valvular AF (NVAF) who were anticoagulation-naïve were enrolled, and all patients were stratified into moderate-to-severe and mild neurologic deficit groups using the National Institutes of Health Stroke Scale on admission. The association between the initial serum D-dimer levels and the LAVI was evaluated in all enrolled patients, and the serum D-dimer levels were compared between the two groups. Results The patients were classified into two groups according to the severity of the neurologic deficit. In a partial correlation coefficient analysis adjusted for confounding factors, an increase in the initial serum D-dimer levels was significantly associated with LAVI (r=0.286; p=0.027). A linear regression analysis showed that a history of peripheral artery disease was the factor most strongly associated with the serum D-dimer level (t=3.90, p<0.001), followed by LAVI (t=2.37, p=0.021) and a history of congestive heart failure (t=2.16, p=0.035). The D-dimer levels were higher in the moderate-to-severe neurologic deficit group than in the mild deficit group, but this difference was not statistically significant (4.5±7.1 vs. 1.6±2.6 mg/L, p=0.068). Conclusion The serum D-dimer levels were significantly associated with LAE in anticoagulation-naïve patients with an acute ischemic stroke and NVAF.

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A 63-year-old Japanese man whose white blood cell count and total-bilirubin and aminotransferase levels were elevated was referred to our hospital. Computed tomography did not reveal any abnormalities, and there was no evidence of gastritis or colitis on esophagogastroduodenoscopy. Although the patient had no history of drug use or allergies, a high concentration of eosinophils (80%) was noted. A liver biopsy revealed hepatitis with eosinophilic infiltration. The patient's alanine aminotransferase and eosinophil levels improved with the administration of steroids. A second biopsy, performed 6 months later, showed the improvement of the eosinophilic infiltration. The patient was diagnosed with eosinophilic hepatitis due to the presence of hypereosinophilic syndrome without the dysfunction of other organs.

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An 84-year-old woman was diagnosed with symptomatic severe aortic stenosis. She had previously undergone aortobifemoral bypass grafting (Y graft) for bilateral iliac stenosis. In view of a high surgical risk, a decision for transcatheter aortic valve implantation (TAVI) was made. An incision was made on the right limb of the Y graft and subsequently a 16 Fr e-sheath was smoothly advanced through the graft. A 23 mm balloon expandable valve was then advanced with no resistance and successfully deployed. This case highlights the feasibility of TAVI through the graft, but requires a thorough preprocedural assessment of the access route using multiple imaging modalities.

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A 25-year-old previously healthy man was hospitalized for syncope. While standing, he suddenly lost consciousness, followed by a generalized tonic clonic seizure. An electrocardiogram demonstrated asystole. No cardiac abnormalities were detected on the echocardiogram, cardiac magnetic resonance imaging (MRI), positron emission tomography, or a coronary angiogram. An electrophysiological study showed normal sinus node and atrioventricular node function. An electroencephalogram revealed small spike waves in the fronto-temporal region. Brain MRI demonstrated a left-sided amygdala enlargement. To the best of our knowledge, this is the first case of temporal lobe epilepsy with an amygdala enlargement that induced cardiac asystole.

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The major puncture-site complications of the transfemoral approach are retroperitoneal bleeding (RPB), arteriovenous (AV) fistula, and arterial pseudoaneurysm. Although the management of RPB and AV fistula depends on individual cases, our experience shows that the use of a covered stent with intravascular ultrasound (IVUS) guidance can successfully manage percutaneous coronary intervention-associated RPB and AV fistula. IVUS guidance can therefore make it easy to use an optimal-size covered stent.

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Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of severe pulmonary hypertension. According to previously reported studies in the pertinent literature, chronic inflammatory conditions may be implicated in the development of CTEPH. We herein describe the case of a 56-year-old woman who was diagnosed with CTEPH in association with chronic infection. The patient had experienced five episodes of pneumonia in the five years prior to the diagnosis of CTEPH. Blood tests from the previous five years of outpatient follow-up demonstrated that the C-reactive protein level was slightly elevated. This case suggests that a relationship exists between chronic inflammation and CTEPH, and furthermore, may contribute towards elucidating the pathophysiology of CTEPH.

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Excessive dynamic airway collapse (EDAC) has been diagnosed using dynamic CT during inspiration and expiration. We herein report an asthma patient with EDAC that was detected incidentally using nondynamic CT. The patient presented with wheezing, cough and mild fever. Treatment for the asthma did not improve her wheeze. CT revealed tracheal narrowing and bulging of the posterior bronchial wall. The patient was diagnosed with EDAC by bronchoscopy. Her wheeze improved with continuous positive airway pressure therapy. Clinicians should be aware of the airway shape when performing nondynamic CT in refractory asthma patients because recognizing the existence of EDAC may help when deciding on the treatment strategy.

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A 54-year-old man was referred to our hospital because of progressive dyspnea. Chest computed tomography showed multiple nodular shadows with a peripheral ground-glass halo. His clinical condition continued to deteriorate with the development of progressive respiratory failure requiring mechanical ventilation. A histological examination of a transbronchial lung biopsy revealed choriocarcinoma. The patient died within nine days of admission. A histological examination of the right testis during an autopsy revealed a burned-out testicular tumor consisting of a teratoma and a fibrous scar. We herein report a rare case of pulmonary multiple metastatic choriocarcinoma originating from a burned-out testicular tumor.

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A 68-year-old woman was scheduled to undergo percutaneous embolization of a pulmonary arteriovenous malformation (PAVM) to prevent a paradoxical embolic event. After contrast-enhanced computed tomography (CT) was performed to carefully evaluate the PAVM, she developed acute interstitial nephritis, which required steroid therapy. Moreover, her D-dimer level increased, which was suggestive of thrombus formation. After nine months, we noted that the affected vessels had markedly decreased in size, and the fistula had almost disappeared on unenhanced CT images. To our knowledge, this is the first case report to describe the regression of a PAVM, detected by CT, after the onset of acute interstitial nephritis.

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Pure red cell aplasia (PRCA), a type of anemia, occurred in a 50-year-old man six weeks after a splenectomy. It was successfully controlled by ciclosporin A (CsA) treatment. However, the onset of acute autoimmune hemolytic anemia (AIHA) developed one week after the CsA had been tapered off. Fortunately, the AIHA responded well to a high-dose methylprednisolone and immunoglobulin treatment. Unexpectedly, the patient suffered from severe pulmonary infection three months after the AIHA therapy. Four months later, he completely stopped the methylprednisolone. The disease was diagnosed as large granular T-lymphocytic leukemia by T cell receptor gene rearrangement, a surface marker examination and immunohistochemical staining. To our knowledge, no similar cases have previously been reported in the literature.

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A 41-year-old man was admitted to our hospital because of a cancer-related stroke (CRS) caused by a thrombus of the extracranial carotid artery. He had undergone neoadjuvant radiochemotherapy for metastatic colorectal adenocarcinoma. The serum D-dimer values were within the normal range. We treated him with intravenous unfractionated heparin followed by warfarin. There were no recurrent stroke events over six months. The leading cause of a CRS is an embolism caused by hypercoagulopathy, mainly represented by non-bacterial thrombotic endocarditis. However, it was unusual that, in the current case, a thrombus of the extracranial carotid artery was formed with no significant residual stenosis, thus resulting in an artery-to-artery embolism.

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