Objective Elderly gastrointestinal bleeding (GIB) patients sometimes cannot be discharged home. In some cases, they die after hemostasis, even following appropriate treatment. This study investigates the clinical backgrounds and outcomes of elderly Japanese GIB patients.
Methods The medical records of 185 patients (123 men, 62 women; mean age 68.2 years; range 10-99 years) with GIB symptoms who underwent esophagogastroduodenoscopy or colonoscopy to detect or treat the source of GIB were retrospectively reviewed. We compared the outcomes between patients ≤70 (n=85) and >70 (n=100) years. The clinical backgrounds of the patients who died or changed hospitals to undergo rehabilitation or receive palliative care were evaluated, as were the association of four factors with these poor outcomes: GIB (re-bleeding or uncontrolled bleeding), endoscopic procedure-related complications, exacerbation of the pre-existing comorbidity, and any complications that were not directly related to GIB.
Results Of the patients ≤70 and >70 years of age, three (3.5%) and 17 (17.0%), respectively, were transferred to another hospital (p=0.003). One (1.2%) and five (5.0%), respectively, died (p=0.144). All three patients ≤70 years old that changed hospitals did so because their comorbidities became worse. The reasons for changing hospitals in the 17 patients >70 years of age included exacerbation of a pre-existing comorbidity (41.1%, 7/17), other complications (35.4%, 6/17), GIB itself (17.6%, 3/17), and endoscopic procedure-related complications (5.9%, 1/17).
Conclusion Although non-elderly and elderly GIB patients had similar mortality rates, many more elderly patients could not be discharged home for various reasons.

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Objective Heparin is not recommended to be administered during the interruption of antiplatelet therapy for non-cardiac surgery. However, there are insufficient data to determine the value. The purpose of the present study was to evaluate the clinical results of the administration of unfractionated heparin during the interruption of antiplatelet therapy in non-cardiac surgery patients who had previously undergone drug-eluting stent (DES) implantation.
Methods We retrospectively identified 210 elective non-cardiac surgical procedures that were performed with the administration of unfractionated heparin during interruption of all antiplatelet therapies in patients who had previously undergone DES implantation. Heparin was administered during the perioperative period in accordance with the local practice guideline at out institution. We examined the clinical outcomes within 30 days of surgery.
Results The mean number of implanted DESs was 2.1±1.3. No major adverse cardiac events (including cardiac death, definite stent thrombosis, and non-fatal myocardial infarction) occurred in any of the 210 cases within 30 days of surgery. Four of the 210 cases (1.9%) required reoperation for bleeding within 30 days of surgery.
Conclusion Our data showed the potential for the perioperative management with unfractionated heparin administration in Japanese patients who had previously undergone DES implantation who required non-cardiac surgery with the interruption of all antiplatelet therapies.

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Objective Pleural effusion is rarely observed in patients with multiple myeloma (MM). Myeloma cell infiltration or invasion to the pleura is very rare. This study aimed to investigate the clinical characteristics of pleural effusion in patients with MM.
Methods We retrospectively reviewed the medical records of patients diagnosed with pleural effusion, MM, and pleural effusion with MM between 2004 and 2014 at Beijing Jishuitan Hospital. The present study included patients with pleural effusion who underwent cytological, bacteriological, biochemical and other testing. The cytopathology of abnormal pleural effusion cells was not diagnostic, thus flow cytometry was performed. MM was defined using the diagnosis standard of NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) 2014 for MM.
Results This study included 3,480 pleural effusion patients and 319 MM patients. There were 34 patients with both MM and pleural effusion (17 men and 17 women). The average age was 63 years (range, 48-84 years). Pleural effusion with MM was caused by congestive heart disease, chronic renal failure, hypoalbuminemia, pulmonary infarctions, cirrhosis, pulmonary arterial hypertension, parapneumonic effusion, tuberculous pleural effusion, and myelomatous pleural effusion (MPE). The diagnosis of MPE was confirmed by the detection of myeloma cells in the pleural fluid using flow cytometric analyses. There were only 2 MPE cases in our study. The first MPE case was a woman. The first clinical manifestation was pleural effusion, and the diagnosis was non-secretory MM, DSS stage IIIA (Durie-Salmon staging system); ISS stage I (the International Staging System). The second MPE case was a man who was diagnosed with MM IgA-κ, DSS stage IIIA; ISS stage II.
Conclusion The detection rate of MPE was very low. MPE tended to present with yellow exudates and the lack of physical and chemical characteristics. Furthermore, patients with MPE exhibited many yellow nodules on the pleura. These nodules were lobulated and had abundant blood supply. The routine pleural effusion pathological examination had low sensitivity. Flow cytometry may be more useful for improving the detection rate of MPE.

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Objective Adherence to rehabilitation exercise is much lower in patients with hematologic malignancies (22.5-45.8%) than in patients with solid tumors (60-85%) due to the administration of more intensive chemotherapeutic regimens in the former. Virtual reality exercise can be performed even in a biological clean room and it may improve the adherence rates in elderly patients with hematologic malignancies. Thus, in this pilot study, we aimed to investigate the feasibility and safety of virtual reality exercise intervention using Nintendo Wii Fit in patients with hematologic malignancies receiving chemotherapy.
Methods In this feasibility study, 16 hospitalized patients with hematologic malignancies aged ≥60 years performed virtual reality exercise for 20 minutes using the Nintendo Wii Fit once a day, five times a week, from the start of chemotherapy until hospital discharge. The adherence rate, safety, and physical and psychological performances were assessed.
Results The adherence rate for all 16 patients was 66.5%. Nine patients completed the virtual reality exercise intervention with 88 sessions, and the adherence rate was 62.0%. No intervention-related adverse effects >Grade 2, according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0, were observed. We noted maintenance of the physical performance (e.g., Barthel index, handgrip strength, knee extension strength, one-leg standing time, and the scores of timed up and go test and Instrumental Activities of Daily Living) and psychosocial performance (e.g., score of hospital anxiety and depression scale).
Conclusion Virtual reality exercise using the Wii Fit may be feasible, safe and efficacious, as demonstrated in our preliminary results, for patients with hematologic malignancies receiving chemotherapy.

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Drug-eluting stents (DES) are widely used for the treatment of coronary artery disease, and a sirolimus-eluting stent (SES; Cypher) was the first DES introduced into clinical practice. Although pathological reactions of coronary arteries to SES have been described in autopsy cases, there are few reports regarding calcification of the coronary arteries after SES implantation.
The present report describes the findings of an autopsy conducted 16 months after SES implantation that showed remarkable persistent calcification. In addition, previously reported pertinent pathological findings are also described.

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An asymptomatic 40-year-old woman with a first-degree atrioventricular block presented a right atrial mass in transthoracic echocardiograms. Transesophageal echocardiograms showed abnormally thickened tissue on the interatrial septum, which extended around the aortic annulus. Multimodality examinations demonstrated lesions in the heart, lungs, liver, and spleen, suggesting sarcoidosis. She was diagnosed with cardiac sarcoidosis after we detected granulomas in a lung specimen. A right atrial mass shrunk following steroid therapy. We should therefore consider the possibility of cardiac sarcoidosis when we see wall thickening and a mass echo in the atrium. These signs may point to an early-phase lesion of cardiac sarcoidosis.

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We herein report the case of a 68-year-old man receiving hemodialysis who developed severe hypoglycemia. He became unconscious and exhibited a blood glucose level below 10 mg/dL. We ruled out the possibility of other causes; however, severe hypoglycemia was observed even after starting glucose injections. The patient developed pneumonia and finally died. Although we conducted an autopsy, there were no specific findings explaining the severe hypoglycemia. We believe that carnitine deficiency was possibly involved in the severe hypoglycemia observed in this case. Physicians should be aware of the possibility of carnitine deficiency and/or severe hypoglycemia, especially in hemodialysis patients with malnutrition.

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We herein report the case of an elderly woman with bone pain and proteinuria as the main clinical manifestations. The patient was diagnosed with the IgG κ type of multiple myeloma. Her renal pathology consisted of widespread κ light chain protein deposition associated with the formation of large quantities of rod-like crystals in podocytes. This phenomenon is very rare. We explored the significance of this crystal formation via a detailed and descriptive analysis and also performed a literature review, thus providing data to increase the available information about this type of disease.

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A 53-year-old woman who had undergone deceased donor kidney transplantation twice, at 35 and 43 years of age, presented with renal impairment. She was infected with hepatitis C virus (HCV). The histology of the graft kidney revealed post-transplant membranous nephropathy (MN) with podocytic infolding and antibody-mediated rejection (AMR). IgG subclass staining showed fine granular deposits of IgG1 and IgG3, but not IgG4, in the glomerular capillary walls. Panel reactive antibody scores for human leukocyte antigen class I and class II were 92.67% and 66.68%, respectively. Thus, this case of post-transplanted MN was considered to be associated with AMR and HCV infection.

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A 54-year-old man was referred to our hospital due to a mass shadow noted on a chest X-ray. Thoracoscopic lobectomy yielded a diagnosis of primary pulmonary synovial sarcoma according to the histology and SYT-SSX1 gene analyses. Five months after the thoracic surgery, he developed brain metastasis; therefore, we performed resection of the brain metastatic focus followed by radiotherapy. As a local recurrence in the thoracic cavity concurrently emerged, systemic chemotherapy was also administered. These observations indicated that a multidisciplinary approach may be useful against primary pulmonary synovial sarcoma, although there is presently no established therapeutic strategy due to its rarity and highly aggressive nature.

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A 64-year-old Japanese man with mild reticular shadows in both lungs developed a lung tumor causing ectopic Cushing's syndrome. He was prescribed an adrenal inhibitor, which controlled his hypercortisolemia. However, he developed acute exacerbation of idiopathic pulmonary fibrosis (IPF) and died within weeks. Previous studies have suggested a dosage reduction of corticosteroids for IPF as a triggering event for acute exacerbation. The present case suggests that IPF coexisting with Cushing's syndrome may have been exacerbated after the correction of hypercortisolemia. Therefore, close monitoring of cortisol levels along with the clinical course of IPF is required in similar cases that require the correction of hypercortisolemia.

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We herein report a unique case of donor cell leukemia (DCL), as donor cell-derived lymphoid blast crisis of chronic myeloid leukemia (CML) was observed 24 years after related bone marrow transplantation for CML in the chronic phase. Short tandem repeat testing of the leukemic blast sample revealed full donor chimerism, strongly indicative of DCL. The original donor is healthy with a normal complete blood cell count for the past 24 years. This rare case may provide a precious opportunity to consider not only the underlying mechanism of DCL, but also the pathogenesis of CML.

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Gamma heavy chain disease (gHCD) is a rare lymphoproliferative disorder characterized by the production of a truncated immunoglobulin heavy chain. Although some cases of gHCD are concurrent with other lymphoid neoplasms, few have been reported. We herein present the case of a 73-year-old woman with gHCD and T-cell large granular lymphocytic leukemia. A multiparameter flow cytometry analysis revealed neoplastic cells that were positive for CD28, a marker of T-cell activation, the anti-apoptotic antigen of neoplastic plasma cells, CD38 and CD45. The results of this multiparameter flow cytometry analysis may contribute to furthering the understanding of the clinicopathological features of gHCD.

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Chronic neutrophilic leukemia (CNL) is a rare form of myeloproliferative neoplasm characterized by the drastic elevation of mature neutrophils. One of the major causes of death among patients with CNL is severe bleeding; however, the difficulty of accurately diagnosing this disease has caused confusion in this field. Recently, somatic mutations of the CSF3R gene have been associated with CNL. This has led to the establishment of more accurate diagnostic criteria for CNL. We herein report a case study of a patient with CNL with a T618I point mutation on the CSF3R gene who showed severe bleeding.

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An 87-year-old man taking antihypertensive medications, including 10 mg enalapril, daily visited our hospital complaining of motor aphasia, dysarthria, and right hemiparesis. Magnetic resonance imaging revealed an ischemic lesion in the left frontal lobe including the insular cortex and severe stenosis of the left middle cerebral artery. After he received intravenous alteplase infusion, he developed orolingual angioedema followed by transient bradycardia with subsequent hypotension, resulting in the deterioration of his neurological signs and expansion of the ischemic lesion. Orolingual angioedema after intravenous alteplase infusion may follow cardiovascular instability and disease progression in stroke patients.

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A 69-year-old man presented with upper airway symptoms, multiple lung nodules and masses, proteinuria and hematuria, and an increased level of proteinase 3 anti-neutrophil cytoplasmic antibody (PR3-ANCA). Granulomatosis with polyangiitis (GPA) was diagnosed by a transbronchial lung biopsy. All of these symptoms were ameliorated and the level of PR3-ANCA declined following treatment with prednisolone and cyclophosphamide. The patient developed a headache 16 months after the onset of symptoms, and contrast-enhanced magnetic resonance imaging showed the thickening of the dura mater, which suggested that hypertrophic pachymeningitis (HP) had developed as a complication of GPA. HP can be a unique complication of GPA at recurrence, and can occur without the relapse of other lesions or an increase in PR3-ANCA level.

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