Endoscopy-assisted transoral resection of a parapharyngeal space schwannoma without mandibular dissection

副咽頭間隙腫瘍切除術では，下顎離断により良好な視野を得られるが，その手術侵襲は大きい．本論文では佐藤式彎曲型喉頭鏡，nerve integrity monitoring（NIM）， narrow-band imaging（NBI）などの手術支援器具を用いて，頸部高位に存在する巨大交感神経鞘腫に対して下顎離断を行うことなくtransorally using video-laryngoscopic surgery（TOVS）により経口腔的切除し得た一例を報告する

Hemorrhagic infarction at 33 days after birth in a healthy full-term neonate

Intraparenchymal hemorrhage in the full-term neonate rarely occurs more than 2 weeks after birth, and its definitive cause remains unclear. In the present report, a case of a patient with intraparenchymal hemorrhage occurring 33 days after birth is described. Histological examination of the brain tissue obtained during hematoma evacuation through craniotomy showed hemorrhagic infarction. Patent foramen ovale may have been present and this may have led to spontaneous paradoxical cerebral embolism followed by hemorrhagic infarction

Narrow band imaging accentuates differences in contrast between cartilage and perichondrium in the elevation of the muco-perichondrium flap during septoplasty and open septorhinoplasty

鼻中隔矯正術において区別が難しい軟骨と軟骨膜を白色光（White light; WL）と狭帯域光観察（Narrow band imaging; NBI）で観察した．軟骨と軟骨膜の間の輝度の差はWLよりNBIで有意に大きかった．得られた画像を赤・緑・青に分光すると，赤では有意に輝度の差がみられた．以上からNBIを用いると軟骨と軟骨膜の間のコントラストが強調されることが示された．また，このコントラストの強調はNBIの赤色の処理によることが示された

Purinergic P2Y(6) receptors heterodimerize with angiotensin AT1 receptors to promote angiotensin II-induced hypertension

The angiotensin (Ang) type 1 receptor (AT1R) promotes functional and structural integrity of the arterial wall to contribute to vascular homeostasis, but this receptor also promotes hypertension. In our investigation of how Ang II signals are converted by the AT1R from physiological to pathological outputs, we found that the purinergic P2Y6 receptor (P2Y6R), an inflammation-inducible G protein (heterotrimeric guanine nucleotide–binding protein)–coupled receptor (GPCR), promoted Ang II–induced hypertension in mice. In mice, deletion of P2Y6R attenuated Ang II–induced increase in blood pressure, vascular remodeling, oxidative stress, and endothelial dysfunction. AT1R and P2Y6R formed stable heterodimers, which enhanced G protein–dependent vascular hypertrophy but reduced β-arrestin–dependent AT1R internalization. Pharmacological disruption of AT1R-P2Y6R heterodimers by the P2Y6R antagonist MRS2578 suppressed Ang II–induced hypertension in mice. Furthermore, P2Y6R abundance increased with age in vascular smooth muscle cells. The increased abundance of P2Y6R converted AT1R-stimulated signaling in vascular smooth muscle cells from β-arrestin–dependent proliferation to G protein–dependent hypertrophy. These results suggest that increased formation of AT1R-P2Y6R heterodimers with age may increase the likelihood of hypertension induced by Ang II

Positron emission tomography assessments of phosphodiesterase 10A in patients with schizophrenia

[Background and hypothesis] Phosphodiesterase 10A (PDE10A) is a highly expressed enzyme in the basal ganglia, where cortical glutamatergic and midbrain dopaminergic inputs are integrated. Therapeutic PDE10A inhibition effects on schizophrenia have been reported previously, but the status of this molecule in the living patients with schizophrenia remains elusive. Therefore, this study aimed to investigate the central PDE10A status in patients with schizophrenia and examine its relationship with psychopathology, cognition, and corticostriatal glutamate levels. [Study design] This study included 27 patients with schizophrenia, with 5 antipsychotic-free cases, and 27 healthy controls. Positron emission tomography with [18F]MNI-659, a specific PDE10A radioligand, was employed to quantify PDE10A availability by measuring non-displaceable binding potential (BPND) of the ligand in the limbic, executive, and sensorimotor striatal functional subregions, and in the pallidum. BPND estimates were compared between patients and controls while controlling for age and gender. BPND correlations were examined with behavioral and clinical measures, along with regional glutamate levels quantified by the magnetic resonance spectroscopy. [Study results] Multivariate analysis of covariance demonstrated a significant main effect of diagnosis on BPND (p = .03). A posthoc test showed a trend-level higher sensorimotor striatal BPND in patients, although it did not survive multiple comparison corrections. BPND in controls in this subregion was significantly and negatively correlated with the Tower of London scores, a cognitive subtest. Striatal or dorsolateral prefrontal glutamate levels did not correlate significantly with BPND in either group. [Conclusions] The results suggest altered striatal PDE10A availability and associated local neural dysfunctions in patients with schizophrenia

Trastuzumab-Based Combination Chemotherapy in Patients with Human Epidermal Growth Factor Receptor-2-Positive Metastatic Carcinoma ex Pleomorphic Adenoma

Background: Carcinoma ex pleomorphic adenoma (CXPA) is a rare histologic subtype of lacrimal gland and submandibular gland cancer. Currently, there is no standard treatment for metastatic CXPA, although some case reports have explored the role of targeted agents in chemotherapy. A few histopathologic analyses have shown that some of these tumors overexpress human epidermal growth factor receptor-2 (HER2), suggesting a potential role for HER2-based therapy. We report here two cases of metastatic CXPA that were treated with trastuzumab-based chemotherapy (IRB approved) with rapid and significant responses. Case Report 1: A 66-year-old male was diagnosed as HER2-positive CXPA of the right lacrimal gland with multiple bone and lymph node metastases. Combination chemotherapy with trastuzumab (Tmab) and nanoparticle albumin-bound paclitaxel (nabPTX) was initiated. A rapid response was confirmed, and after seven cycles of treatment, CR(complete response) was achieved. Case Report 2: A 67-year-old female was diagnosed with HER2 positive CXPA of the right submandibular gland. Multiple pulmonary metastatic lesions were detected after surgery, and combination chemotherapy with Tmab and nab-PTX was initiated. A rapid partial response (PR) was confirmed, and she eventually became disease-free. Conclusion: In the absence of definitive clinical trials, which are unlikely to be performed due to the rarity of HER2-positive CXPA, therapeutic information must be obtained from case reports. Some reports, such as this one, have suggested a potential utility of trastuzumab-based chemotherapy

免疫抑制剤投与中に急性呼吸促迫症候群を合併した粟粒結核の１例

症例は75歳，女性．MPO-ANCA 関連血管炎に対して半年間，ステロイド薬が投与されていた．４日前から発熱，呼吸困難が出現，意識障害も伴ってきたため，当院を受診した．画像上，両側肺にびまん性の中枢側に有意な浸潤影とすりガラス陰影を認め，急性呼吸促迫症候群（ARDS）の合併を疑われた．人工呼吸管理となり，挿管中に採取した喀痰抗酸菌検査で塗抹陽性，結核菌PCR陽性の結果が得られ，血液や尿からも結核菌が検出され，粟粒結核によるARDS と診断した．治療は入院後の第３病日からINH ＋ RFP ＋ EB による抗結核療法を開始し，人工呼吸管理および血液透析をしながら経過観察をしていたが，播種性血管内凝固症候群も併発し，第14病日に死亡した．ARDS を合併する粟粒結核の症例も散見されることから，鑑別診断に粟粒結核も念頭におきながら診療することが重要と思われた．A 75-year-old woman, who was treated with corticosteroid therapy for six months for MPO-ANCA related vasculitis, visited to our hospital with fever, dyspnea and consciousness disturbance four days ago. She was diagnosed with acute respiratory distress syndrome (ARDS) from radiological findings such as diffuse bilateral hilar dominant infiltration shadow and ground-glass opacity. She was admitted to the intensive care unit (ICU) and put on mechanical ventilation for acute respiratory failure. The aspiration sputum after incubation turned out to be positive for acid-fast bacilli, which were identified as Mycobacterium tuberculosis (MTB) using a polymerase chain reaction test. As the same results in the clinical specimens of peripheral blood and urine were obtained, we made final diagnosis of miliary tuberculosis complicated with ARDS. Although we initiated the anti-tuberculosis treatment using INH, RFP, EB with mechanical ventilation and hemodialysis treatment, she died of multiple organ failure complicated with disseminated intravascular coagulation (DIC). Due to the fact, that we have encountered few cases of miliary tuberculosis complicated with ARDS, it is important that we suspect severe miliary tuberculosis in patients with immunosuppressive treatment

急速に増大する腫瘤影を呈した肺Mycobacterium avium症の1例

症例は66歳,男性.慢性閉塞性肺疾患とい草塵肺で経過観察をしていた.6カ月前の胸部CTでは明らかな異常を認めなかったが,新たに左上葉の気腫性病変周囲に腫瘤性病変を認めた.気管支鏡検査にて,局所検体からM.avium が検出されたものの生検で肉芽腫病変を認めなかったため,CTガイド下肺生検を実施した結果,肺MAC症と最終診断した.近年,孤立性腫瘤形成型肺MAC症の症例を散見するようになってきているが,本症例のごとく短期間で急速に増大することもあることから,抗酸菌を含めた肺感染症に対する積極的な検査が必要と思われる.A 66-year-old man was admitted to our hospital for follow-up on chronic obstructive pulmonary disease with a recent-showing abnormal chest shadow. He had received a periodic chest computed tomography (CT) six months prior due to a past history of COPD and Igusa pneumoconiosis. Although there was no mass shadow on the chest CT six months ago, a solitary tumorous shadow appeared surrounding the emphysematous lesions in the left upper lobe. M. avium was detected from local specimens viabronchoscopic examination, but because a granulomatous lesion was not observed, we performed a CT-guided lung biopsy and made a final diagnosis of pulmonary MAC disease. We recently observed that pulmonary MAC disease presents as a solitary tumorous shadow. However, as there are cases of pulmonary MAC disease presenting as a rapidly growing tumorous shadow within a short time, it is necessary to perform aggressive examinations for infectious diseases including an acid-fast bacilli examination

胸部リンパ節病変の診断における超音波気管支内視鏡ガイド 下経気管支針生検(EBUS-TBNA)の有用性

近年,超音波気管支内視鏡ガイド下経気管支針生検(Endobronchial Ultrasonography-guided Transbronchial Needle Aspiration,以下EBUS-TBNA)は縦隔および肺門リンパ節病変に対するアプローチ法として開発され,病理学的および微生物学的な確定診断に用いられる.EBUSTBNAを実施できるか否かの判断や,施行後の診断率には標的リンパ節の大きさや周囲もしくは内部血管などが影響するが,それらに関する報告は少ない.2010年10月～2013年8月に,当科でEBUSを施行した69例のTBNA施行率,診断率,不成功の理由を後方視的に検討した.TBNAを施行できたのは60例であり(87%),そのうち54例(93%)で診断が確定できた.肺癌が42例(67%)と最多で,以下サルコイドーシス7例,他臓器癌のリンパ節転移3例,抗酸菌感染症1例,悪性リンパ腫1例であった.EBUS施行例のリンパ節の直径は21.3±6.0mmで,非確診例の標的リンパ節は有意に小さかった(17.5±3.7vs22.9±5.1mm,p<0.0001).部位別では下部気管傍リンパ節と気管支分岐部リンパ節で実施した症例が多かったが,部位による診断率の差は認めなかった.最終診断率では,肺癌が91%(46例中42例),サルコイドーシスが70%(10例中7例)であった.TBNAの不成功の理由は,「標的リンパ節が小さい」,「血管損傷の可能性が高い」,「患者の鎮静不可」であった.重篤な有害事象は1例も認めなかった.縦隔および肺門リンパ節病変の診断において,EBUS-TBNAは有用であると考えられた.Endobronchial ultrasonography - guided transbronchial needle aspiration (EBUSTBNA) is a new method for tissue biopsy of thoracic lymph node lesion. However, the clinical usefulness of this method and associated issues are still relatively unknown. Sixty-nine cases received EBUS in our hospital between October 2010 and August 2013. The relationship was analyzed between the diagnostic rate and the size or location of the lymph node targeted. TBNA was performed in 60 of the 69 cases, out of those the pathological and microbiological diagnosis were obtained in 54 cases (93%). The final diagnosis consisted of lung cancer in 42 cases (67%) followed by sarcoidosis in 7, metastasis of the other organ\u27s malignancy in 3 and mycobacterium infection in 1, and lastly malignant lymphoma in 1. The mean lymph node diameter was 21.3 ± 6.0 mm, and the inability to obtain the correct diagnosis was significantly smaller than obtaining the correct diagnosis. (17.5 ± 3.7 vs 22.9 ± 5.1 mm, p < 0.0001). In regard to the location of the lymph nodes, "lower paratrachea" and " subcarinal" were common, but was not chief concern with the diagnostic rate. Futhermore, the diagnostic rate was 91% (42 of 46) in lung cancer and 70% (7 of 10) in sarcoidosis. We could not perform EBUS-TBNA because of "small lymphnode" and "high risk of vascular damage" in addition to "insufficient patient\u27s sedation". No severe adverse events had occurred. EBUS-TBNA is useful for the thoracic lymph node lesion diagnosis