Removal of diminutive colorectal polyps: A prospective randomized clinical trial between cold snare polypectomy and hot forceps biopsy

AIMTo compare the efficacy and safety of cold snare polypectomy (CSP) and hot forceps biopsy (HFB) for diminutive colorectal polyps.METHODSThis prospective, randomized single-center clinical trial included consecutive patients ≥ 20 years of age with diminutive colorectal polyps 3-5 mm from December 2014 to October 2015. The primary outcome measures were en-bloc resection (endoscopic evaluation) and complete resection rates (pathological evaluation). The secondary outcome measures were the immediate bleeding or immediate perforation rate after polypectomy, delayed bleeding or delayed perforation rate after polypectomy, use of clipping for bleeding or perforation, and polyp retrieval rate. Prophylactic clipping after polyp removal wasn’t routinely performed.RESULTSTwo hundred eight patients were randomized into the CSP (102), HFB (106) and 283 polyps were evaluated (CSP: 148, HFB: 135). The en-bloc resection rate was significantly higher with CSP than with HFB [99.3% (147/148) vs 80.0% (108/135), P < 0.0001]. The complete resection rate was significantly higher with CSP than with HFB [80.4% (119/148) vs 47.4% (64/135), P < 0.0001]. The immediate bleeding rate was similar between the groups [8.6% (13/148) vs 8.1% (11/135), P = 1.000], and endoscopic hemostasis with hemoclips was successful in all cases. No cases of perforation or delayed bleeding occurred. The rate of severe tissue injury to the pathological specimen was higher HFB than CSP [52.6% (71/135) vs 1.3% (2/148), P < 0.0001]. Polyp retrieval failure was encountered CSP (7), HFB (2).CONCLUSIONCSP is more effective than HFB for resecting diminutive polyps. Further long-term follow-up study is required.

Clinical utility of treatment method conversion during single-session endoscopic ultrasound-guided biliary drainage

BACKGROUND Although several techniques for endoscopic ultrasound-guided biliary drainage(EUS-BD)are available at present,an optimal treatment algorithm of EUS-BD has not yet been established.AIM To evaluate the clinical utility of treatment method conversion during single endoscopic sessions for difficult cases in initially planned EUS-BD.METHODS This was a single-center retrospective analysis using a prospectively accumulated database.Patients with biliary obstruction undergoing EUS-BD between May 2008 and April 2016 were included.The primary outcome was to evaluate the improvement in EUS-BD success rates by converting the treatment methods during a single endoscopic session.Secondary outcomes were clarification of the factors leading to the conversion from the initial EUS-BD and the assessment of efficacy and safety of the conversion as judged by technical success,clinical success,and adverse events(AEs).RESULTS A total of 208 patients underwent EUS-BD during the study period.For 18.8%(39/208)of the patients,the treatment methods were converted to another EUSBD technique from the initial plan.Biliary obstruction was caused by pancreatobiliary malignancies,other malignant lesions,biliary stones,and other benign lesions in 22,11,4,and 2 patients,respectively.The reasons for the difficulty with the initial EUS-BD were classified into the following 3 procedures:Target puncture(n=13),guidewire manipulation(n=18),and puncture tract dilation(n=8).Technical success was achieved in 97.4%(38/39)of the cases and clinical success was achieved in 89.5%of patients(34/38).AEs occurred in 10.3%of patients,including bile leakage(n=2),bleeding(n=1),and cholecystitis(n=1).The puncture target and drainage technique were altered in subsequent EUSBD procedures in 25 and 14 patients,respectively.The final technical success rate with 95%CI for all 208 cases was 97.1%(95%CI:93.8%-98.9%),while that of the initially planned EUS-BD was 78.8%(95%CI:72.6%-84.2%).CONCLUSION Among multi-step procedures in EUS-BD,guidewire manipulation appeared to be the most technically challenging.When initially planned EUS-BD is technically difficult,treatment method conversion in a single endoscopic session may result in successful EUS-BD without leading to severe AEs.

Perivascular Fat Attenuation Index on Non-Contrast-Enhanced Cardiac Computed Tomography: Comparison with Coronary Computed Tomography Angiography

Objective: Perivascular fat attenuation index (FAI) measurement on non-contrast-enhanced cardiac computed tomography (NCCT) has not been rigorously validated in previous studies. Herein, we compared perivascular FAI values between NCCT and coronary computed tomography angiography (CCTA). We also investigated the variability and reproducibility of perivascular FAI measurement. Methods: A total of 44 patients who underwent NCCT and CCTA were included in this study. For NCCT, perivascular FAI was measured using three threshold settings: from −30 to −190 Hounsfield Units (HU), −20 to −180 HU, and −10 to −170 HU. For CCTA, perivascular FAI was measured using one threshold setting: from −30 to −190 HU. Perivascular FAI measurements by NCCT were compared with those by CCTA using the paired t-test, and correlations were assessed using Pearson’s correlation coefficient. The intra- and inter-observer variabilities for the measurements with NCCT and CCTA were evaluated with the intraclass correlation coefficient. Results: Perivascular FAI measurements with the threshold setting of −30 to −190 HU were significantly lower on NCCT than on CCTA. There were no significant differences between the perivascular FAI measurements at the remaining thresholds on NCCT and those on CCTA. The perivascular FAI at all thresholds on NCCT correlated significantly with those on CCTA. The intra- and inter-observer agreements were excellent for the measurements on NCCT and CCTA. Conclusion: There were significant differences between the perivascular FAI measurements on NCCT and CCTA. However, the differences could be modified by threshold adjustment.

An Isolated Case of Brachyphalangism of the Basal Finger Bones of the Little Finger with Symptoms of Tenosynovitis: A Case Report

Brachydactyly is a general term that refers to disproportionately short fingers and toes and forms a part of the group of limb malformations characterized by bone dysostosis. Brachydactyly usually occurs either as an isolated malformation or as a part of a complex malformation syndrome. Brachydactyly is classified as types A, B, C, D, or E;brachymetatarsus IV;Sugarman brachydactyly;or Kirner deformity. Various types of isolated brachydactyly are rare, except for types A3 and D. We describe a 15-year-old girl with isolated brachyphalangism of the basal finger bones of the little finger with symptoms of tenosynovitis. Tenosynovitis might be caused by growth deviation between the flexor digitorum superficialis and the flexor digitorum profundus. The patient responded very well to surgical treatment.

Desmoid Tumor Causing Hip Joint Contracture: A Case Report

Desmoid tumor (DT) is a relatively uncommon, cytologically bland fibrous neoplasm that is associated with possibility of local recurrence but without the potential to spread to other parts of the body. This disease affects mostly younger adults and is the most common cause of abdominal wall masses in women 20 - 35 years of age. However, it may involve nearly every body part, including the extremities, head and neck, trunk, and abdominal cavity;as such, patients with DT may present to a range of general and subspecialty radiologists. The consensus for treatment has changed over the past decade, with most centers moving away from primary radical surgery towards a front-line “wait-and-see” policy. Here, we present a case of a tumor mass that induced hip joint contracture. DT does not usually cause functional disorder. Oncologists should be aware that a desmoid tumor can cause hip joint contracture if the mass occurs in the gluteal region. Moreover, DT resulting in such a functional disorder should be treated by resection.

Low-Grade Fibromyxoid Sarcoma in the Left Gluteal Region Presenting as Sciatic Nerve Pain

Low-grade fibromyxoid sarcoma is a slowly growing soft tissue neoplasm, mostly affecting young individuals. It usually arises in a deep soft tissue of the lower limbs and trunk, but few cases of low-grade fibromyxoid sarcoma that presents sciatic nerve pain have been reported. We report a 34-year-old woman with a low-grade fibromyxoid sarcoma originating in the left gluteal region that initially presented as sciatic nerve pain;she had experienced this type of pain for 5 years before visiting our hospital. Magnetic resonance imaging revealed a tumor in the left gluteal region. After needle biopsy revealed it to be a low-grade fibromyxoid sarcoma, we performed the wide resection. Intra-operative findings revealed no tumor invasion into the sciatic nerve. No recurrence or metastasis has been detected 6 months post-surgery. Oncologists who encounter patients with sciatic nerve pain should consider the possibility of less common causes such as the low-grade fibromyxoid sarcoma found in our patient.

Serum Albumin Levels in Emergency Patients with Low BMI

A low body mass index (BMI) is often associated with low nutritional status and adverse health outcomes. While the BMI is used in describing “thinness” meaning cachexia, serum albumin levels were also used in assessing patient’s nutritional conditions. Object: A retrospective study was conducted to determine whether the extremes of BMI and/or cachexia increased the morbidity and mortality in our critical emergency department. Methods: A hundred and five cases with low BMI (≤18.5 kg/m2) were chosen from the patients who were admitted to our critical emergency department from Sept 2013 to Aug 2016. The relationship between serum albumin levels on admission and prognosis were analyzed. Results: No significant correlations were observed between body mass index and albumin levels in thin patients. Lower levels of serum albumin (p Conclusions: Even with low BMI, if the albumin value was 3.3 g/dL or more, the prognosis was good in our emergency department. Estimation of albumin level on admission is not only a simple and objective way to assess the nutritional status but also a useful outcome predictor of critically ill patients coming to emergency centers.

To Investigate the Effect of Using Ethanol Containing Wipes in Collecting Blood for the Measurement of Alcohol Concentration

This study was aimed to establish whether the skin preparation using ethanol-containing skin antiseptics causes ethanol contamination through blood collection. Venous blood was collected from 40 healthy volunteers according to the national guidelines for blood sampling, with four sequential procedures as follows: 1) collecting blood immediately (within 5 seconds) after cleaning the skin with an individually packaged type of ethanol-containing wipe, 2) collecting blood 1 minute after cleaning the skin with an individually packaged type of ethanol-containing wipe, 3) collecting immediately (within 5 seconds) after cleaning the skin with a traditional cleaning method (thoroughly ethanol-impregnated wipe, and 4) collecting 1 minute after cleaning the skin with a traditional cleaning method. Each sequential procedure was performed with and without the ethanol-containing wipe used for skin cleaning on the puncture site on their right and left arms at the time the needle was withdrawn, respectively. The collected specimens were subjected to the determination of ethanol by using headspace gas chromatography-mass spectrometry. In every 80 blood specimens obtained from 40 participants, ethanol was undetectable (<0.001 mg/mL). This study demonstrates that disinfection using ethanol-containing skin antiseptics is unlikely to cause ethanol contamination through blood collection regardless of skin preparation technique according to the guidelines for blood sampling. This may have implications in forensic science.

A Super-Aged Case with Marked Hyponatremia Reaching 98 mEq/L;Clinical Implications of Low Serum Sodium

A 79-year-old man, an in-patient at a long-term hospital suffers from Alzheimer dementia and thyroid hypofunction. Recently, he had also suffered from pneumonia followed by impaired consciousness and referred to our hospital for further examination. At the time of admission, the level of consciousness was JCS III-200 and other vital signs were normal. He had no edema on his limbs but had dry skin. According to chest CT, we detected pneumonia. Based on the laboratory data on admission, we detected low osmolality of 206 mOsm/kg of water and serum Na 98 mEq/L, beside urinary Na 54.1 mEq/L. We confirmed severe hyponatremia of hypersecretion type. Fluid replacement therapy was started mainly with Ringer’s solution which is similar to extracellular fluid. We diagnosed it as SIADH induced by adrenal crisis based on the significant lower serum Na value and low blood sugar. Consequently, the patient was administered Hydrocortisone and Fludrocortisone acetate. On the 14th day, serum Na level improved from 98 mEq/L to 140 mEq/L. After daily monitoring of serum Na and urinary Na, administration of fludrocortisone acetate was terminated. The patient was discharged on 25th day, since serum Na was stabilized with oral administration of hydrocortisone and oral salt supplement. This case report shows that adrenal crisis can be triggered by pneumonia. In cases of impaired consciousness, if hyponatremia and hypoglycemia are observed, we may have to suspect the possibility of adrenal crisis. Therefore, urinary biochemical examination is an important part of the laboratory tests.

A review of isolated muscular ventricular septal defect

Background Color Doppler echocardiography greatly facilitates the diagnosis of isolated muscular ventricular septal defect with a small shunt.Data sources Original research articles were collected from database,including PubMed and Google scholar.Relevant articles about muscular ventricular septal defect were included.Results The frequency of isolated muscular ventricular septal defect is 5.7%in preterm infants and 1.1-5.3%in term infants.Spontaneous closure in muscular ventricular septal defect occurs with higher frequency and earlier than in perimembranous ventricular septal defect.Approximately 80-90%of isolated muscular ventricular septal defect closes spontaneously by 12 months of age.Midventricular muscular ventricular septal defect is spontaneously closed earlier in the short term,but no site difference is found in the long term.The spontaneous closure mechanism is regarded as aposition of the muscle tissueor fibrous tissue formation in the right ventricular side,but in rare cases involves aneurysm formation of the fibrous tissue.Regarding spontaneous closure of isolated muscular ventricular septal defect diagnosed for the fetus,further studies are needed.Chromosomal microarray analysis of fetuses with isolated muscular ventricular septal defect has revealed that it is not a severe risk factor of chromosomal abnormalities.Conclusions This paper presents a review of the history of the diagnosis and frequency of ventricular septal defect,with discussion of its natural history from the fetal period to after birth in patients with isolated muscular ventricular septal defect.

Apalutamide for patients with metastatic castrationsensitive prostate cancer in East Asia:a subgroup analysis of the TITAN trial

Ethnicity might be associated with treatment outcomes in advanced prostate cancer.This study aimed to evaluate the efficacy and safety of androgen deprivation therapy(ADT)combined with apalutamide in East Asians with metastatic castration-sensitive prostate cancer(mCSPC).The original phase 3 Targeted Investigational Treatment Analysis of Novel Anti-androgen(TITAN)trial was conducted at 260 sites in 23 countries.This subgroup analysis included patients enrolled in 62 participating centers in China,Japan,and Korea.Radiographic progression-free survival(PFS),time to prostate-specific antigen(PSA)progression,and PSA changes from baseline were compared between groups in the East Asian population.The intent-to-treat East Asian population included 111 and 110 participants in the apalutamide and placebo groups,respectively.The 24-month radiographic PFS rates were 76.1%and 52.3%in the apalutamide and placebo groups,respectively(apalutamide vs placebo:hazard ratio[HR]=0.506;95%confidence interval[CI],0.302–0.849;P=0.009).Median time to PSA progression was more favorable with apalutamide than placebo(HR=0.210;95%CI,0.124–0.357;P<0.001).Median maximum percentages of PSA decline from baseline were 99.0%and 73.9%in the apalutamide and placebo groups,respectively.The most common adverse event(AE)was rash in the apalutamide group,with a higher rate than that in the placebo group(37.3%vs 9.1%).The most common grade 3 or 4 AEs were rash(12[10.9%])and hypertension(12[10.9%])for apalutamide.The efficacy and safety of apalutamide in the East Asian subgroup of the TITAN trial are consistent with the global results.