Significance of secretory leukocyte peptidase inhibitors in pleural fluid for the diagnosis of benign asbestos pleural effusion

Background Secretory leukocyte peptidase inhibitor (SLPI) is a biomarker present in the respiratory tract that protects against tissue destruction and aids wound healing. However, it is difficult to distinguish early-stage malignant pleural mesothelioma (MPM) from benign asbestos pleural effusion (BAPE) presenting as pleural effusion in diagnostic imaging. More biomarkers of pleural effusion are needed to identify early-stage MPM. We examined whether SLPI in pleural effusion can be used to distinguish BAPE from MPM and other conditions that involve pleural effusion. Methods We measured levels of SLPI, hyaluronic acid (HA), soluble mesothelin-related peptides (SMRP), galectin-3, CCL2, and CYFRA21-1 in 51 BAPE patients, 37 MPM patients, 77 patients with pleural effusions due to non-small cell lung cancer (LCa), and 74 patients with other pleural effusions diagnosed at Okayama Rosai Hospital. Results SLPI levels in pleural fluid of BAPE patients were significantly lower (p < 0.0001) than those in patients with MPM, LCa, and other pleural effusions. The area under curve (AUC) for SLPI’s ability to distinguish BAPE from MPM was 0.902, with a sensitivity of 82.4% and a specificity of 86.5%. These values were not only favorable, but were better than the AUC for the ability to distinguish BAPE from HA (0.802), and SMRP (0.746). Galectin-3 levels were significantly lower in patients with BAPE compared with those in patients with MPM and the other two diseases, whereas CCL2 levels were significantly higher in patients with BAPE compared with patients with MPM and the other two diseases. Moreover, CYFRA21-1 levels were significantly lower in BAPE patients compared with levels in patients with MPM and LCa. Using these six markers enabled BAPE to be distinguished from MPM and other diseases. As a single marker, SLPI proved to be superior to HA and SMRP for the diagnosis of BAPE. Conclusions The measurement of pleural fluid SLPI as well as HA and SMRP is useful as a biomarker to diagnose BAPE, which needs to be distinguished from early-stage MPM.

Feasibility of a Modified SCC Method With and Without Combining the Use of PGA Sheets and Fibrin Glue for Preventing Delayed Bleeding After Gastric ESD

Background: Some methods have been developed for preventing delayed bleeding (DB) after gastric endoscopic submucosal dissection (GESD). However, none of the methods can completely prevent DB. We hypothesized that DB can be prevented by a modified the search, coagulation, and clipping (MSCC) method for patients at low risk of DB and by combining the use of PGA sheets and fibrin glue with the MSCC method (PMSCC method) for patients at high risk of DB (anti-bleeding [ABI] strategy). In this study, the technical feasibility of this novel strategy was assessed.Methods: We investigated 123 lesions in 121 consecutive patients who underwent GESD in Kushiro Rosai Hospital between April 2018 and January 2020. The decision for continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment.Results: Oral antithrombotic agents were administered to 28 patients (22.8%). En bloc R0 resection rate was 98.4%. The MSCC method and PMSCC method for preventing were performed in 114 and 9 lesions, respectively. The median time of the MSCC method was 16 min and the median speed was 3.6 cm2/10min. The median time of the PMSCC method was 59 min and the median speed was 1.3 cm2/10min. The only delayed procedural adverse event was DB in one (0.8%) of the 123 lesions. Conclusions: The ABI strategy is feasible for preventing DB in patients at low risk and high risk of DB after GESD, whereas the PMSCC method may be necessary for reduction of time.

Evaluation of Cortisol Production in Aldosterone-Producing Adenoma

Aldosterone-producing adenoma (APA) is sometimes accompanied with subclinical hypercortisolism. We investigated the ability of cortisol production in APA, both clinically and pathologically. A retrospective cohort study was conducted at Yokohama Rosai Hospital from 2009 to 2016. Thirty patients with APA and serum cortisol levels during the 1 mg dexamethasone suppression test (F-DST)<3.0 μg/dl were included. We evaluated the 1) difference between pre-adrenalectomy F-DST (pre-F-DST) and post-adrenalectomy F-DST (ΔF-DST), 2) correlation between ∆F-DST and pre-F-DST, tumour size determined by CT, and type of adrenalectomy (total or partial), and 3) relationship between the ratio of F-DST divided by tumour size (ΔF-DST/pre-F-DST/mm) and immunoreactivity of CYP17A1, CYP11B1, and CYP11B2. The median [interquartile range] age was 48 [38–58] years. We found a significant decrease in F-DST after adrenalectomy [before: 1.4 (1.1–1.8); after: 0.9 (0.6–1.2); p<0.001]. Additionally, a significant correlation was found for ΔF-DST and both pre-F-DST (Spearman, ρ=–0.68, p<0.001) and tumour size (ρ=–0.51, p 0.005). No significant difference was found in ΔF-DST between total and partial adrenalectomy. CYP17A1 and CYP11B1 were positive in 21 (100%) and 17 (81%) adenomas, respectively. CYP17A1 immunoreactivity in the tumour was significantly related with ΔF-DST/pre-F-DST/mm (p 0.049). F-DST significantly decreased after adrenalectomy, and most of the adenomas were immunohistochemically positive for CYP17A1 and CYP11B1 as well as CYP11B2. We should consider the possibility of autonomous cortisol production as well as hyperaldosteronism in the evaluation and treatment of APA patients.

Hypnotics Use and Falls in Hospital Inpatients Stratified by Age

<p><strong>BACKGROUND:</strong> Little is known about the association between hypnotics use and falls among inpatients in young and middle-aged populations. We aimed to determine whether the use of hypnotics elevated the fall risk in adult inpatients aged 20 and above.</p><p><strong>METHODS:</strong> Patients admitted to the Kanto Rosai Hospital, Kanagawa, Japan, between April 1, 2013 and January 31, 2014 were followed up until discharge. We estimated the incidence rate ratio (IRR) and 95% confidence intervals (CI) of falls for the use of hypnotic drugs with a Poisson regression model, adjusted for sex, age, activities of daily living, and comorbidities.</p><p><strong>RESULTS:</strong> For the 6,949 inpatients whose medical records were examined, the incidence of falls was significantly higher in hypnotics’ users than in non-users. The IRR was 1.52 (95% CI, 1.10-2.11). When stratified by age, the risk of hypnotics use in the patients aged 65 and above was statistically elevated (IRR, 1.48; 95% CI, 1.02-2.13); the risk in the patients aged 25-64 was elevated but not significant (IRR, 1.33; 95% CI, 0.63-2.81).</p><p><strong>CONCLUSION:</strong> Usage of hypnotics elevated fall risk in the older inpatients, though this association was not significant in the young and middle-aged inpatients. Further studies are needed.</p>

Gallstone Ileus following Endoscopic Stone Extraction

An 85-year-old woman was an outpatient treated at Tokyo Rosai Hospital for cirrhosis caused by hepatitis B. She had previously been diagnosed as having common bile duct stones, for which she underwent endoscopic retrograde cholangiopancreatography (ERCP). However, as stone removal was unsuccessful, a plastic stent was placed after endoscopic sphincterotomy. In October 2012, the stent was replaced endoscopically because she developed cholangitis due to stent occlusion. Seven days later, we performed ERCP to treat recurring cholangitis. During the procedure, the stone was successfully removed by a balloon catheter when cleaning the common bile duct. The next day, the patient developed abdominal pain, abdominal distension, and nausea and was diagnosed as having gallstone ileus based on abdominal computed tomography (CT) and abdominal ultrasonography findings of an incarcerated stone in the terminal ileum. Although colonoscopy was performed after inserting an ileus tube, no stone was visible. Subsequent CT imaging verified the disappearance of the incarcerated stone from the ileum, suggesting that the stone had been evacuated naturally via the transanal route. Although it is extremely rare for gallstone ileus to develop as a complication of ERCP, physicians should be aware of gallstone ileus and follow patients carefully, especially after removing huge stones.

Proposed mechanism for cyst formation and enlargement following Gamma Knife Surgery for arteriovenous malformations

Object The authors retrospectively studied the mechanism of cyst formation and enlargement after Gamma Knife surgery (GKS) for arteriovenous malformations (AVMs). Methods Eighteen patients in whom cyst formation developed following GKS for AVM were retrospectively identified among 775 patients who underwent GKS for AVM at Yokohama Rosai Hospital. The study group was composed of 12 male and 6 female patients ranging in age from 17 to 47 years. Results Chronic encapsulated expanding hematoma was associated with the cyst in 5 patients. The AVM nidus volume at the time of GKS ranged from 1.9 to 36 cm3, and the prescription radiation dose was 18–25 Gy. Complete obliteration of the AVM nidus was obtained in 13 patients and partial obliteration in 5 patients. Cyst formation was detected between 2.6 and 15 years after GKS. Craniotomy was performed in 10 patients, including 2 patients in whom the incompletely obliterated nidus was removed at the same time, and an Ommaya reservoir was placed in 2 patients. Spontaneous regression of the cyst was observed in 1 patient. Serial MR imaging was performed in the other patients because the size of the cyst was stable or the lesion was asymptomatic. Histological examination of the cyst wall revealed linear hemosiderin deposits with gliosis. The nodular lesion, which was enhanced on MR images, contained granulation tissue with chronic hemorrhage from newly developed capillary vessels. Conclusions Cysts developing after GKS for AVM enlarge mainly due to repeated minor hemorrhages from a reddish nodular angiomatous lesion that develops within an adjacent brain area. Thus, the optimal treatment is wide opening of the cyst with removal of the associated angiomatous lesion by craniotomy.