We report a case of unilateral tonic pupil in spinocerebellar ataxia without brainstem atrophy in a 42- year-old man. On neurological examination, he showed cerebellar symptoms and unilateral tonic pupil. Deep tendon reflexes were normal except for brisk patellar tendon reflexes. Brain MRI demonstrated cerebellar atrophy only. There was neither orthostatic hypotension nor bowel and bladder failure. The right pupil constricted from 5.0 mm to 1.7 mm 60 minutes after 0.125% pilocarpine administration, whereas the left pupil did not change, remaining at 3.7 mm. Although it is not proven that tonic pupil is causally related to spinocerebellar ataxia, physicians must remain aware of spinocerebellar ataxia as a disease that can demonstrate tonic pupil.

Recent progress in chemotherapy has prolonged the survival of patients with malignant biliary strictures, leading to increased rates of stent occlusion. Even we employed metallic stents which contributed to higher rates and longer durations of patency, and occlusion of covered metallic stents now occurs in about half of all patients during their survival. We investigated the complication and patency rate for the removal of covered metallic stents, and found that the durations were similar for initial stent placement and re-intervention. In order to preserve patient quality of life, we currently recommend the use of covered metallic stents for patients with malignant biliary obstruction because of their removability and longest patency duration, even though uncovered metallic stents have similar patency durations.
Biliary Tract Diseases/*surgery ; Coated Materials, Biocompatible ; Device Removal ; Drainage/methods ; Endoscopy ; Foreign-Body Migration/surgery ; Humans ; Metals ; Postoperative Complications/surgery ; *Stents/adverse effects

Background/Aims: Cholecystitis can occur after the placement of covered self-expandable metallic stents for distal malignant biliary obstructions. We aimed to identify risk factors for cholecystitis following covered self-expandable metallic stent placement. Methods: We investigated risk factors related to cholecystitis following covered self-expandable metallic stent placement in 118 patients with distal malignant biliary obstructions between January 1, 2015 and April 30, 2019. Endoscopic assessments and tumor invasion to the arteries feeding the gallbladder were determined by a pancreaticobiliary endoscopist and a radiologist, respectively. Results: The median patient age was 72 years (men, 61.0%). The flow of the contrast agent into the gallbladder and tumor involvement in the orifice of the cystic duct were observed in 35 (29.7%) and 35 (29.7%) patients, respectively. During the observation period (median, 179 days), cholecystitis occurred in 18 (15.3%) patients. Multivariate analysis revealed the flow of the contrast agent into the gallbladder (p=0.023) and tumor involvement in the orifice of the cystic duct (p=0.005) as significant independent risk factors associated with cholecystitis. Conclusions The flow of the contrast agent into the gallbladder and tumor involvement in the orifice of the cystic duct are potential independent risk factors for cholecystitis following the placement of covered self-expandable metallic stents. A follow-up prospective study is warranted to validate their influence.

Background/Aims: Cholecystitis can occur after the placement of covered self-expandable metallic stents for distal malignant biliary obstructions. We aimed to identify risk factors for cholecystitis following covered self-expandable metallic stent placement. Methods: We investigated risk factors related to cholecystitis following covered self-expandable metallic stent placement in 118 patients with distal malignant biliary obstructions between January 1, 2015 and April 30, 2019. Endoscopic assessments and tumor invasion to the arteries feeding the gallbladder were determined by a pancreaticobiliary endoscopist and a radiologist, respectively. Results: The median patient age was 72 years (men, 61.0%). The flow of the contrast agent into the gallbladder and tumor involvement in the orifice of the cystic duct were observed in 35 (29.7%) and 35 (29.7%) patients, respectively. During the observation period (median, 179 days), cholecystitis occurred in 18 (15.3%) patients. Multivariate analysis revealed the flow of the contrast agent into the gallbladder (p=0.023) and tumor involvement in the orifice of the cystic duct (p=0.005) as significant independent risk factors associated with cholecystitis. Conclusions The flow of the contrast agent into the gallbladder and tumor involvement in the orifice of the cystic duct are potential independent risk factors for cholecystitis following the placement of covered self-expandable metallic stents. A follow-up prospective study is warranted to validate their influence.

Background/Aims: In stereomicroscopic sample isolation processing, the cutoff value (≥4 mm) of stereomicroscopically visible white cores indicates high diagnostic sensitivity. We aimed to evaluate endoscopic ultrasound-guided tissue acquisition (EUS-TA) using a simplified stereomicroscopic on-site evaluation of upper gastrointestinal subepithelial lesions (SELs). Methods: In this multicenter prospective trial, we performed EUS-TA using a 22-gauge Franseen needle in 34 participants with SELs derived from the upper gastrointestinal muscularis propria, requiring pathological diagnosis. The presence of stereomicroscopically visible white core (SVWC) in each specimen was assessed using stereomicroscopic on-site evaluation. The primary outcome was EUS-TA’s diagnostic sensitivity with stereomicroscopic on-site evaluation based on the SVWC cutoff value (≥4 mm) for malignant upper gastrointestinal SELs. Results: The total number of punctures was 68; 61 specimens (89.7%) contained stereomicroscopically visible white cores ≥4 mm in size. The final diagnoses were gastrointestinal stromal tumor, leiomyoma, and schwannoma in 76.5%, 14.7%, and 8.8% of the cases, respectively. The sensitivity of EUS-TA with stereomicroscopic on-site evaluation based on the SVWC cutoff value for malignant SELs was 100%. The per-lesion accuracy of histological diagnosis reached the highest level (100%) at the second puncture. Conclusions Stereomicroscopic on-site evaluation showed high diagnostic sensitivity and could be a new method for diagnosing upper gastrointestinal SELs using EUS-TA.

Objective: Cervical dystonia (CD) is a clinically under-recognized symptom occurring at the later- to end-stages of Parkinson’s disease (PD). The frequency of CD and its influence on prognosis have not been well studied. Here, we conducted an in-depth examination of CD incidence and impact on disease progression in later-stage PD. Methods: We retrospectively reviewed the clinical features of 22 deceased patients with sporadic PD treated at a hospital in Japan from 1983 to 2008. Results: The most common cause of death in PD was pneumonia. CD, in particular retrocollis, was frequent in the later stages of the disease in elderly patients (9/22, 40.9%). Pneumonia incidence increased sharply in the later period with CD. There was a positive trend between CD duration and duration of pergolide use. Conclusion: Analysis revealed that CD increases markedly in late- to end-stage PD, which may be associated with aspiration pneumonia due to dysphagia. Pathological mechanisms underlying CD might be influenced by treatments including dopamine agonists. Prevention of CD may increase quality of life and prolong survival of PD patients.