Recurrent ventricular arrhythmia due to aconite intoxication successfully treated with landiolol:A case report

BACKGROUND Ventricular arrhythmias,such as ventricular tachycardia and fibrillation,are the main causes of death in patients with aconite poisoning.CASE SUMMARY A 51-year-old man presented to our emergency department because he was vomiting after ingesting aconite root to attempt suicide.On arrival,the patient was hemodynamically unstable,and his electrocardiogram revealed polymorphic ventricular extrasystoles and non-sustained ventricular tachycardia.Amiodarone was immediately administered for ventricular arrhythmia.However,the patient remained unresponsive.We administered continuous intravenous landiolol as the ventricular arrhythmia worsened,gradually suppressing it.The patient returned to sinus rhythm 16 h after arriving at the hospital.Some aconitum alkaloids act on voltage-gated Na+-channels and induce ventricular or supraventricular tachyarrhythmias.Landiolol suppresses sympathetic nerve activity through its blocking effect,preventing arrhythmia.CONCLUSION Landiolol can be a therapeutic option for amiodarone-refractory ventricular arrhythmias caused by aconite intoxication.

Feasibility of Estimating Patient-Specific Dose Verification Results Directly from Linear Accelerator Log Files in Volumetric Modulated Arc Therapy

The feasibility of estimating patient-specific dose verification results directly from linear accelerator (linac) log files has been investigated for prostate cancer patients who undergo volumetric modulated arc therapy (VMAT). Twenty-six patients who underwent VMAT in our facility were consecutively selected. VMAT plans were created using Monaco treatment planning system and were transferred to an Elekta linac. During the beam delivery, dynamic machine parameters such as positions of the multi-leaf collimator and the gantry were recorded in the log files;subsequently, root mean square (rms) values of control errors, speeds and accelerations of the above machine parameters were calculated for each delivery. Dose verification was performed for all the plans using a cylindrical phantom with diodes placed in a spiral array. The gamma index pass rates were evaluated under 3%/3 mm and 2%/2 mm criteria with a dose threshold of 10%. Subsequently, the correlation coefficients between the gamma index pass rates and each of the above rms values were calculated. Under the 2%/2 mm criteria, significant negative correlations were found between the gamma index pass rates and the rms gantry angle errors (r = 0.64, p < 0.001) as well as the pass rates and the rms gantry accelerations (r = 0.68, p < 0.001). On the other hand, the rms values of the other dynamic machine parameters did not significantly correlate with the gamma index pass rates. We suggest that the VMAT quality assurance (QA) results can be directly estimated from the log file thereby providing potential to simplify patient-specific prostate VMAT QA procedure.

Diagnostic and therapeutic single-operator cholangiopancreatoscopy in biliopancreatic diseases:Prospective multicenter study in Japan

AIM: To assess the utility and safety of single-operator cholangiopancreatoscopy(SOCPS) using the Spy Glass system in widespread clinical application for biliary and pancreatic diseases.METHODS: This study was a prospective case series conducted in 20 referral centers in Japan. There were 148 patients who underwent SOCPS; 124 for biliary diseases and 24 for pancreatic diseases. The attempted interventions were SOCPS examination, SOCPS-directed tissue sampling, and therapy for stone removal, among others. The main outcomes were related to the procedure success rate in terms of visualizing the target lesions, SOCPS-directed adequate tissue sampling, and complete stone removal. RESULTS: A total of 148 patients were enrolled for the diagnosis of indeterminate biliary and pancreatic lesions or treatment of biliary and pancreatic disease. The overall procedure success rate of visualizing the target lesions was 91.2%(135/148). The overall procedural success rates of visualizing the target lesions of diagnostic SOCPS in the bile duct and pancreatic duct were 95.5%(84/89) and 88.2%(15/17), respectively. Diagnosis: the overall adequate tissue for histologic examination was secured in 81.4% of the 86 patients who underwent biopsy under SOCPS(bile duct, 60/75, 80.0%; pancreatic duct, 10/11, 90.9%). The accuracy of histologic diagnosis using SOCPS-directed biopsies in indeterminate bile duct lesions was 70.7%(53/75). In the pancreatic duct, the accuracy of SOCPS visual impression of intraductal papillary mucinous neoplasm was 87.5%(14/16). Stone therapy: complete biliary and pancreatic stone clearance combined with SOCPS-directed stone therapy using electrohydraulic lithotripsy or laser lithotripsy was achieved in 74.2%(23/31) and 42.9%(3/7) of the patients, respectively. Others: SOCPS using the Spy Glass system was used in cannulation of the cystic duct in two patients and for passing across the obstructed self-expandable metallic stent for a malignant biliary stricture in two patients. All procedures were successful in both SOCPS-guided therapies. The incidence of procedure-related adverse events was 5.4%(8/148). CONCLUSION: SOCPS with direct visualization and biopsy for diagnosis and SOCPS-directed therapy for biliary and pancreatic diseases can be safely performed with a high success rate.

Management of the late effects of disconnected pancreatic duct syndrome: A case report

BACKGROUND There have been few reports about the late effects of disconnected pancreatic duct syndrome(DPDS). Although few reports have described the recurrence interval of pancreatitis, it might be rare for recurrence to occur more than 5 years later.Herein, we describe a case of recurrence in an 81-year-old man after the treatment of walled-off necrosis(WON) with pancreatic transection 7 years ago.CASE SUMMARY An 81-year-old man visited our hospital with chief complaints of fever and abdominal pain 7 years after the onset of WON due to severe necrotic pancreatitis. His medical history included an abdominal aortic aneurysm(AAA),hypertension, dyslipidemia, and chronic kidney disease. Computed tomography(CT) scan showed that the pancreatic fluid collection(PFC) had spread to the aorta with inflammation surrounding it, and CT findings suggested that bleeding occurred from the vasodilation due to splenic vein occlusion. First, we attempted to perform transpapillary drainage because of venous dilation around the residual stomach and the PFC. However, pancreatic duct drainage failed because of complete main pancreatic duct disruption. Second, we performed endoscopic ultrasound-guided drainage. After transmural drainage, the inflammation improved and stenting for the AAA was performed successfully. The inflammation was resolved, and he has been free from infection for more than 2 years after the procedure.CONCLUSION This case highlights the importance of continued follow-up of patients for recurrence after the treatment of WON with pancreatic transection.

Laparoscopic cholecystectomy for gangrenous cholecystitis in around nineties: Two case reports

BACKGROUND Gangrenous cholecystitis is a form of acute cholecystitis which involves gangrenous alterations in the gallbladder wall and it often follows an acute and serious course.We herein report on two cases of very elderly people diagnosed early with gangrenous cholecystitis,who safely underwent laparoscopic cholecystectomy(LC)and both demonstrated a good outcome.CASE SUMMARY Case 1:An 89-year-old female.She underwent abdominal contrast-enhanced computed tomography(CECT)due to abdominal pain and diarrhea.Her gallbladder wall indicated the absence of contrast enhancement,thus leading to diagnosis of gangrenous cholecystitis and she therefore underwent LC.Although her gallbladder demonstrated diffuse necrosis and it was also partly perforated,she was able to be discharged without any serious complications.Case 2:A 91-year-old female.She made an emergency visit with a chief complaint of abdominal pain.Abdominal CECT revealed swelling of the gallbladder and an ambiguous continuity of the gallbladder wall.She was diagnosed with gangrenous cholecystitis and underwent LC.Her gallbladder had swelling and diffuse necrosis.Although her preoperative blood culture was positive,she showed a good outcome following surgery.CONCLUSION Although a definite diagnosis of gangrenous cholecystitis is difficult to make prior to surgery,if an early diagnosis can be made and appropriate treatment can be carried out,then even very elderly individuals may be discharged without major complications.

Usability of Deformable Image Registration for Adaptive Radiotherapy in Head and Neck Cancer and an Automatic Prediction of Replanning

Deformable image registration (DIR) has been an important component in adaptive radiotherapy (ART). Our goal was to examine the accuracy of ART using the dice similarity coefficient (DSC) and to determine the optimal timing of replanning. A total of 22 patients who underwent volume modulated arc therapy (VMAT) for head and neck (H&N) cancers were prospectively analyzed. The planning target volume (PTV) was to receive a total of 70 Gy in 33 fractions. A second planning CT scan (rescan) was performed at the 15th fraction. The DSC was calculated for each structure on both CT scans. The continuous variables to predict the need for replanning were assessed. The optimal cut-off value was determined using receiver operating characteristic (ROC) curve analysis. In the correlation between body weight loss and DSC of each structure, weight loss correlated negatively with DSC of the whole face (rs = -0.45) and the face surface (rs = -0.51). Patients who required replanning tended to have experienced rapid weight loss. The threshold DSC was 0.98 and 0.60 in the whole face and the face surface, respectively. Patients who showed low DSC in the whole face and the face surface required replanning at a significantly high rate (P < 0.05 and P < 0.01). Weight loss correlated with DSC in both the whole face and the face surface (P < 0.05 and P < 0.05). The DSC values in the face predicted the need for replanning. In addition, weight loss tended to correlate with DSC. DIR during ART was found to be a useful tool for replanning.

DICOM-RT Plan Complexity Verification for Volumetric Modulated Arc Therapy

The purpose of this study was to investigate the relationship between plan parameters verified with DICOM-RT and dosimetric results for volumetric modulated arc therapy (VMAT). We investigated three treatment locations: prostate cancer (ten cases), maxillary sinus cancer (four cases), and malignant pleura mesothelioma (four cases) with treatment plans generated by a MonacoTM treatment planning system (TPS), and delivered with an Elekta SynergyTM linear accelerator. We calculated plan parameters, including gantry and multileaf collimator (MLC) positions, Monitor Units (MU), and millimeters of MLC motion per degree of gantry rotation (mm/degree), and performed quality assurance (QA) with a DICOM-RT plan verification system. We measured the VMAT dose with a two-dimensional diode array detector. The average gamma passing rate with percent dose acceptance criteria and distance to agreement criteria of 2 mm and 2% (2 mm/2%) were 97.4%, 97.8% and 92.0% for prostate cancer, maxillary sinus cancer, and malignant pleural mesothelioma, respectively. The mean 95th percentile value for DICOM-calculated mm/degree was 4.0, 5.2, and 11.1 for prostate cancer, maxillary sinus cancer, and malignant pleural mesothelioma, respectively. The gamma passing rate showed a correlation with calculated mm/degree, with a coefficient of determination (R2) of 0.60. Higher calculated mm/degree values led to increased dosimetric errors. We conclude that dose distribution calculated by a TPS is more reliable at smaller mm/degree.