No prospective, randomized study has been conducted to date in Japan comparing the use of warfarin and rivaroxaban for preventing thrombotic and bleeding events in the perioperative period of catheter ablation （CA） for atrial fibrillation （AF）. This was a prospective, open-label randomized study assessing the safety and efficacy of warfarin and rivaroxaban in the perioperative period of CA for AF. Thrombotic events including silent cerebral lesion （SCL） detected by magnetic resonance imaging （MRI）, bleeding events, and coagulation test results were assessed in correlation with interrupted warfarin or rivaroxaban in the perioperative period of CA for AF. Finally, thirty-six patients （18 men; aged
65±9.4 years） who underwent CA for AF were prospectively enrolled. No instance of symptomatic cerebral infarction occurred, but 12 of 36 patients （33.3％） showed new SCLs during the postprocedural cerebral MRI examination （8/21 in the rivaroxaban group and 4/15 in the warfarin group; P＝0.47）. The duration of hospitalization was significantly shorter in the rivaroxaban group than in the warfarin group （6 vs. 8 days; P＝0.0135）. The incidence of minor bleeding was significantly lower in the rivaroxaban group than in the warfarin group （0％ vs. 26.6％; P＝0.078）. D-dimer concentration was significantly higher in the SCL group than in the no-SCL group （P＝0.024） under warfarin, while the values of protein S
（P＝0.017） and prothrombin time （P＝0.018） were significantly lower in the SCL group than in the no-SCL group under rivaroxaban. Rivaroxaban usage in CA is safer than warfarin usage with respect to the incidence of minor bleeding. In patients receiving rivaroxaban therapy, a lower protein S level may be correlated with the incidence of SCL in CA.
Pulmonary vein isolation（PVI）is an effective treatment for atrial fibrillation（AF）. However, outcomes differ between paroxysmal AF and persistent AF. We analyzed the predictors of recurrence by examining the recurrence group after ablation. Of 372 consecutive patients with AF who underwent PVI between June 2016 and December 2018, we evaluated 250 patients（age, 67±12y, 65％ men）whose left atrium（LA）was constructed using the PENTARAY catheter（BioSense Webster, Los Angeles, CA）, a multipolar electrode catheter with a novel shape and excellent mapping capability. We measured the LA total volume（LATV）, right pulmonary vein＋antrum volume（RPAV）, left PV＋antrum volume（LPAV）, LA central volume（LACV）, and LA bipolar voltage. Of the 250 patients, 78 had persistent AF（recurrence, 20）and 172 had paroxysmal AF（recurrence, 16）. In all patients, LATV, LACV, RPAV, and LPAV were significantly larger in patients with persistent AF than those with paroxysmal AF. The mean LA bipolar voltage in patients with persistent AF was significantly lower than those with paroxysmal AF. In cases of persistent AF, RPAV was significantly larger in the recurrence group than that in the non-recurrence group（15.9±4.8 vs 13.4±5.4ml; P＜0.05）. In cases of paroxysmal AF, there were no differences in any volume between the recurrence and non-recurrence groups. In conclusion, larger right PV is a predictor of AF recurrence after PVI in patients with persistent AF. The right PV is close to the atrial septum and the septopulmonary bundle, and the expansion of RPAV reflects the disruption of these structures, which may be involved in this result.
Mepolizumab is a monoclonal antibody against interleukin-5 used for the treatment of severe asthma. The effect of long-term mepolizumab administration and its persistence in clinical practice is poorly understood. Thus, this study aimed to investigate the effect of long-term administration of mepolizumab in patients with severe asthma. Mepolizumab was administered to 20 patients with severe asthma. We then prospectively followed the patients for 104 weeks to investigate the efficacy of long-term mepolizumab administration in clinical practice. Eleven patients were evaluated for 104 weeks. Mepolizumab administration reduced asthma exacerbations in a year from 52 to 104 weeks and improved asthma control in every period as assessed by questionnaires. Also, blood eosinophil counts decreased at every point, and blood basophil counts decreased at 104 weeks. We compared various parameters among the 11 patients who continued administration for more than 104 weeks and 7 patients who discontinued treatment due to ineffectiveness. Significant differences were observed in disease duration, maximum expiratory flow at 50%, and blood basophil count. Long-term mepolizumab administration improved asthma symptoms in patients with severe asthma and reduced the frequency of exacerbations.
Four male patients admitted to the same ward in the first half of September 201Y were identified to have respiratory syncytial virus（RSV）infection. Their ages ranged from 49 to 85 years（median 72.5）. One patient was infected with human immunodeficiency virus and three patients had hematological malignancies. Following immuno-chromatological testing with a nasal cavity swab, RSV infection was diagnosed. Although blood and sputum cultures were performed in three patients, no significant bacteria were detected. Two cases responded to supportive therapy. However, one patient died secondary to multiple myeloma, and another patient developed pneumonia and died with an exacerbation of leukemia. RSV infections in immunocompromised hosts are associated with a poor prognosis. Early diagnosis will facilitate isolation of infected individuals to prevent hospital outbreaks.
Colorectal neuroendocrine carcinoma（NEC）is extremely rare and has a dismal prognosis. However, no standardized treatment strategy has been established for this lesion. For patients with NEC and distant metastasis, disease stabilization is difficult even after treatment with multidisciplinary strategies including chemotherapy. Here we describe a case of rectal NEC that presented as multiple liver metastases; a favorable prognosis was obtained after treatment with a multidisciplinary strategy that included surgery, irradiation, and chemotherapy. A 66-year-old male presented with diarrhea and constipation. Colonoscopy and a computed tomography（CT）scan revealed a rectal mass involving all of the luminal circumference, after which a diagnosis of NEC was confirmed by pathological examination. A CT scan also revealed several liver metastases in S5, S6, and S8. Abdominoperineal resection with total mesenteric excision and lymphadenectomy, including the lateral area, was performed. After resection, we administered radiation for local disease control in the lateral area. We also administered chemotherapy consisting of cisplatin and irinotecan for the liver metastases because only the endocrine cell component constituted this tumor. After chemotherapy, a CT scan was performed to confirm that the liver metastasis in S5 and S6 had disappeared, and it was shown that the other lesion in S8 had shrunk substantially（it eventually disappeared）. Then, 48 months after resection, all metastatic liver tumors were under good control, and no other recurrent lesion was recognized. In conclusion, a multidisciplinary strategy including optimal chemotherapy seems to be important to achieve a favorable prognosis of NEC of the colorectum with distant metastasis..