Nephroblastomatosis (NBM) is a precursor of Wilms tumor. We herein report a case in which Wilms tumor was initially suspected and the affected kidney was removed.The tumor was subsequently diagnosed as intralobar NBM and a favorable outcome was achieved with postoperative chemotherapy. A 2-year-old boy who presented with gross hematuria was found to have an enlarged left kidney with hydronephrosis.Needle biopsy of the left kidney suggested Wilms tumor and left nephrectomy was performed. The tumor was histopathologically diagnosed as intralobar NBM.Although NBM is regarded as a precancerous lesion, a definite treatment plan has not yet been established. In the present case, we used a similar chemotherapy regimen to that for Wilms tumor. Eight years after the completion of chemotherapy, Wilms tumor has not developed or recurred. Appropriate management plans need to be developed by accumulating similar cases.

Background/Aims: The Heart Failure Association (HFA)-PEFF score is recognized as a simple method to diagnose heart failure (HF) with preserved ejection fraction (HFpEF). This study aimed to evaluate the relationship between HFA-PEFF scores and cardiovascular outcomes in HFpEF patients. Methods: A total of 502 consecutive HFpEF patients were prospectively observed for up to 1,500 days. Cardiovascular outcomes were compared between two groups of patients, defined by their HFA-PEFF scores: those who scored 2–4 (the intermediate-score group) and those who scored 5–6 group (the high-score group). Overall, 236 cardiovascular events were observed during the follow-up period (median, 1,159 days). Results: Kaplan-Meier analysis showed that there were significant differences in composite cardiovascular events and HF-related events between the intermediate-score group and the high-score group (p = 0.003 and p < 0.001, respectively). Multivariate Cox proportional hazards analysis showed that the HFA-PEFF scores significantly predicted future HF-related events (hazard ratio, 1.66; 95% confidence interval [CI], 1.11 to 2.50; p = 0.014); receiver operating characteristic analysis confirmed this relationship (area under the curve, 0.633; 95% CI, 0.574 to 0.692; p < 0.001). The cutoff HFA-PEFF score for the identification of HF-related events was 4.5. Decision curve analysis revealed that combining the HFA-PEFF score with conventional prognostic factors improved the prediction of HF-related events. Conclusions HFA-PEFF scores may be useful for predicting HF-related events in HFpEF patients.

Objective: Human papillomavirus subtypes are predictive indicators of cervical intraepithelial neoplasia (CIN) progression. While colposcopy is also an essential part of cervical cancer prevention, its accuracy and reproducibility are limited because of subjective evaluation. This study aimed to develop an artificial intelligence (AI) algorithm that can accurately detect the optimal lesion associated with prognosis using colposcopic images of CIN2 patients by utilizing objective AI diagnosis. Methods: We identified colposcopic findings associated with the prognosis of patients with CIN2. We developed a convolutional neural network that can automatically detect the rate of high-grade lesions in the uterovaginal area in 12 segments. We finally evaluated the detection accuracy of our AI algorithm compared with the scores by multiple gynecologic oncologists. Results: High-grade lesion occupancy in the uterovaginal area detected by senior colposcopists was significantly correlated with the prognosis of patients with CIN2. The detection rate for high-grade lesions in 12 segments of the uterovaginal area by the AI system was 62.1% for recall, and the overall correct response rate was 89.7%. Moreover, the percentage of high-grade lesions detected by the AI system was significantly correlated with the rate detected by multiple gynecologic senior oncologists (r=0.61). Conclusion Our novel AI algorithm can accurately determine high-grade lesions associated with prognosis on colposcopic images, and these results provide an insight into the additional utility of colposcopy for the management of patients with CIN2.

Non-occlusive mesenteric ischemia (NOMI) after cardiovascular surgery is a disease with a poor prognosis that is difficult to diagnose and treat. We report a case of NOMI diagnosed and treated immediately after open heart surgery. A 77-year-old man was admitted to our hospital due to heart failure. Echocardiography showed the diagnosis of severe aortic stenosis. He underwent surgery for the replacement of the aortic valve. After surgery, the hemodynamics became unstable and lactate continued to rise. Contrast abdominal computed tomography revealed a smaller SMV sign and ischemic area in the intestinal wall. We suspected NOMI, and continuous intravenous administration of prostaglandin was started. Angiography revealed scattered vascular stenosis in the superior and inferior mesenteric arteries, which led to the diagnosis of NOMI, and selective infusion of papaverine hydrochloride was started. Thereafter, hemodynamic improvement was observed and the patient was able to survive. To facilitate early diagnosis and treatment of NOMI, it is important to establish a protocol at the time of onset of illness to ensure smooth treatment.

The left atrium and left atrial appendage have unique genetic anatomical and physiological features. Recently, advances in diagnostic imaging technology have provided much new knowledge. Clinically, the risk of developing atrial fibrillation increases with age. In order to reduce the public health burden such as cerebral infarction caused by atrial fibrillation, we need to find some predictive risk factors and preventive strategies for cerebral infarction and more effective treatments. The new concept of atrial myopathy has emerged, and animal models and human studies have revealed close interactions between atrial myopathy, atrial fibrillation, and stroke through various mechanisms. Structural and electrical remodeling such as fibrosis and deterioration of the balance of autonomic nerves and complicated interactions between these mechanisms lead to deterioration of atrial fibrillation and a continuous vicious cycle, and finally thrombosis in the left atrial appendage. Although anticoagulant therapy for patients with atrial fibrillation is strongly recommended, it is difficult for many patients to continue optimal treatment. In the nearly future, it will be important to understand the anatomy and physiology of the left atrial appendage and to understand the shape changes, size and the changes of autonomic function, and thrombus formation conditions associated with LAA remodeling during atrial fibrillation, and then we should provide early therapeutic intervention.

Background/Aims: Probe-based confocal laser endomicroscopy (pCLE) requires the administration of intravenous (IV) fluorescein. This study aimed to determine the optimal dose of IV fluorescein for both upper and lower gastrointestinal (GI) tract pCLE. Methods: Patients 20 to 79 years old with gastric high-grade dysplasia (HGD) or colorectal neoplasms (CRNs) were enrolled in the study. The dose de-escalation method was employed with five levels. The primary endpoint of the study was the determination of the optimal dose of IV fluorescein for pCLE of the GI tract. The reduced dose was determined based on off-line reviews by three endoscopists. An insufficient dose of fluorescein was defined as the dose of fluorescein with which the pCLE images were not deemed to be visible. If all three endoscopists determined that the tissue structure was visible, the doses were de-escalated. Results: A total of 12 patients with gastric HGD and 12 patients with CRNs were enrolled in the study. Doses were de-escalated to 0.5 mg/kg of fluorescein for both non-neoplastic duodenal and colorectal mucosa. All gastric HGD or CRNs were visible with pCLE with IV fluorescein at 0.5 mg/kg. Conclusions In the present study, pCLE with IV fluorescein 0.5 mg/kg was adequate to visualize the magnified structure of both the upper and lower GI tract.

Background/Aims: Probe-based confocal laser endomicroscopy (pCLE) requires the administration of intravenous (IV) fluorescein. This study aimed to determine the optimal dose of IV fluorescein for both upper and lower gastrointestinal (GI) tract pCLE. Methods: Patients 20 to 79 years old with gastric high-grade dysplasia (HGD) or colorectal neoplasms (CRNs) were enrolled in the study. The dose de-escalation method was employed with five levels. The primary endpoint of the study was the determination of the optimal dose of IV fluorescein for pCLE of the GI tract. The reduced dose was determined based on off-line reviews by three endoscopists. An insufficient dose of fluorescein was defined as the dose of fluorescein with which the pCLE images were not deemed to be visible. If all three endoscopists determined that the tissue structure was visible, the doses were de-escalated. Results: A total of 12 patients with gastric HGD and 12 patients with CRNs were enrolled in the study. Doses were de-escalated to 0.5 mg/kg of fluorescein for both non-neoplastic duodenal and colorectal mucosa. All gastric HGD or CRNs were visible with pCLE with IV fluorescein at 0.5 mg/kg. Conclusions In the present study, pCLE with IV fluorescein 0.5 mg/kg was adequate to visualize the magnified structure of both the upper and lower GI tract.

An 84-year-old woman treated for tuberculosis in childhood presented to our emergency department with chronic cough and massive hemoptysis. Contrast-enhanced computed tomography (CT) on admission revealed a bronchial-pulmonary artery fistula (BPAF) for which she underwent bronchial artery embolization (BAE) and developed hemoptysis postoperatively. Contrast-enhanced CT on admission revealed a connection between the right coronary and a bronchial artery, suggesting coronary-to-bronchial artery communication. Hemoptysis persisted despite coiling of a branch of the right coronary artery. Therefore, we were consulted to perform thoracic endovascular aortic repair (TEVAR), which we performed as a semi-emergency. She did not show hemoptysis or paraplegia postoperatively and was discharged on postoperative day 40. TEVAR is effective for a BPAF in patients in whom BAE cannot control hemoptysis.

Objective: In order to ensure the safety of nursing home residents, it is very important to implement appropriate assistance to ensure compliance with necessary medication. The purpose of this study is to identify issues and to plan solutions for medication assistance.Design: We conducted a workshop involving care workers (CWs), nurses and pharmacists together.Methods: Using the KJ method, participants extracted problems related to medication assistance and planned solutions in a mixed group of CWs, nurses and pharmacists. Questionnaire surveys were conducted for the participants before, immediately after, and 3 months after the workshop.Results: A number of important and urgent issues related to medication assistance were identified. There were differences in the recognition patterns of the importance and urgency of the issues among the three categories of participants. In addition, many possible solutions were proposed. Among these solutions, 25% had been implemented by at least two participants. More than 75 % of participants felt that their awareness of the value of cooperation in medication assistance had been improved by participating in the workshop.Conclusion: These results suggest that a workshop with a group of CWs, nurses and pharmacists in one place is a useful approach for extracting problems and planning effective solutions related to cooperation in medication assistance.

Several complications of cardiopulmonary resuscitation have been reported. Herein we reported a rare case of rupture in a false lumen immediately following chest compressions. A 79-year-old woman underwent a graft replacement surgery of acute Stanford type A aortic dissection. On POD 6 she developed cardiopulmonary arrest from suffocation by phlegm. She was immediately resuscitated with chest compressions, although bloody discharge from the left chest drainage tube increased. A rupture was detected by contrast enhanced computed tomography scan in the false lumen of the descending aorta. There was a risk of post-resuscitative encephalopathy ; therefore, conservative treatment, such as blood transfusion, hemostatic administration and therapeutic hypothermia, were performed. After rewarming the patient, she recovered consciousness without any neurological abnormalities. We should bear the possibility in mind that chest compression carries the risk of residual false lumen rupture.