A 74-year-old man, with a medical background of cryoglobulinemia, had been undergone nonbacterial thrombotic endocarditis with immunotherapy spanning three months. Following a year and three months, he has presented to our institution experiencing acute decompensated heart failure attributable to severe aortic regurgitation （AR），moderate mitral regurgitation （MR），and severe tricuspid regurgitation （TR）．Transesophageal echocardiography revealed aortic valve cusps destruction and anterior mitral valve leaflet vegetation. The potential complications of leukocytoclastic or necrotizing vasculitis due to hypothermic cardiopulmonary bypass in cryoglobulinemia patients were addressed preemptively through preoperative plasmapheresis. During the procedure, tepid core cooling cardiopulmonary bypass at 33℃ and tepid blood cardioplegia solution at 30℃ were employed to mitigate the risk of vasculitis. Urgent aortic valve replacement, mitral vegetation resection, and tricuspid annuloplasty were performed, and the patient was discharged on the 23rd postoperative day without any untoward events.

Urinary incontinence (UI) among older people is a common problem. Several treatments are available for older people with UI including surgery, drug therapies, and behavioral interventions. Recently, much attention has been placed on the behavioral treatments for UI, including pelvic floor muscle (PFM) exercise, weight loss exercise, and thermal therapy, as they have few risks, no side effects, and are effective. These therapies are often recommended as first line treatments for older people with UI. PFM exercise programs often incorporate alternations of fast contractions that are usually held for about two to three seconds interspersed with relaxation intervals of four to five seconds, and sustained contractions, where participants hold the contraction for about eight to ten seconds followed by a relaxation interval of ten to twelve seconds between the contractions. While exercise periods vary between 3 to 24 weeks, 8 to 12 weeks seems to be the most effective length for PFM exercise. The effectiveness of PFM exercise for the improvement of UI has been validated by many studies, with improvement rates ranging widely from 17 to 84%. Also, research has shown that UI is associated with obesity. Increases in body weight cause increases in abdominal wall weight, which in turn increases intra-abdominal pressure and intra-vesicular pressure. Therefore, abdominal fat reduction from exercise may decrease intra-abdominal pressure, perhaps causing improvements in urethral sphincter contraction and, hence, decreasing UI risk. Evidence reveals that PFM exercise and fitness training targeted at reducing modifiable risk factors are effective strategies for treating UI in older people, regardless of UI type.

We report a case of a hemodialysis patient with a calcified amorphous tumor (CAT) located in Left ventricular outflow tract. A 69-year-old female with chronic kidney disease on hemodialysis for 10 years complained about palpitation and chest tightness. Echocardiography and cardiac MRI revealed a mobile mass in the left ventricular outflow tract (LVOT). We had a follow-up 6 months after finding mass. We thought that as the mass had potential for embolism, we should remove it; we performed an operation, tumor resection without harming the aortic valve. Her clinical course was uneventful. Pathological examination showed that the mass contained calcified nodules and fibrotic tissue. These findings showed CAT.

This study aimed to examine characteristics of physical functions, physical activity, and cognitive functions among community-dwelling older people who stopped driving automobiles. Participants were 589 community-dwelling older people (age: 65–89, 71.4 ± 5.1 years; 403 men, 186 women). The participants underwent nine physical assessments—hand grip strength, knee extension strength, timed up-and-go test, chair stand, one leg standing with open eyes, functional reach, vertical jump, preferred gait speed, maximal gait speed—and were evaluated for physical activity; and five cognitive assessments—the Mini-Mental State Examination (MMSE), Logical Memory I and II (WMS-R LM-I, LM-II) subtests of the Wechsler Memory Scale-Revised; and Trail Making Test A and B (TMT-A, TMT-B). They were divided into current driver (379 men, 169 women) and driving cessation (24 men, 17 women) groups. Among men, the driving cessation group had poorer vertical jump, TMT-A, and TMT-B results, while women had poorer hand grip strength, one leg standing with open eyes, WMS-R LM-II, and LM-II results, and longer inactivity time, compared with the current driver group and adjusted for covariates (P < 0.05 for all). The findings suggest driving cessation among community-dwelling older people is significantly associated with poorer physical functions, physical activity, and cognitive functions compared with those in current drivers.

BACKGROUND/AIMS: This study aimed to examine the diagnostic ability of endoscopic ultrasonography (EUS) for major vascular invasion in pancreatic cancer and to evaluate the relationship between EUS findings and pathological distance. METHODS: In total, 57 consecutive patients who underwent EUS for pancreatic cancer before surgery were retrospectively reviewed. EUS image findings were divided into four types according to the relationship between the tumor and major vessel (types 1 and 2: invasion, types 3 and 4: non-invasion). We also compared the EUS findings and pathologically measured distances between the tumors and evaluated vessels. RESULTS: The sensitivity, specificity, and accuracy of EUS diagnosis for vascular invasion were 89%, 92%, and 91%, respectively, in the veins and 83%, 94%, and 93%, respectively, in the arteries. The pathologically evaluated distances of cases with type 2 EUS findings were significantly shorter than those of cases with type 3 EUS findings in both the major veins (median [interquartile range], 96 [0–742] µm vs. 2,833 [1,076–5,694] µm, p=0.012) and arteries (623 [0–854] µm vs. 3,097 [1,396–6,000] µm, p=0.0061). All cases with a distance of ≥1,000 µm between the tumors and main vessels were correctly diagnosed. CONCLUSIONS: Tumors at a distance ≥1,000 µm from the main vessels were correctly diagnosed by EUS.
Arteries ; Diagnosis ; Endosonography ; Humans ; Pancreatic Neoplasms ; Retrospective Studies ; Sensitivity and Specificity ; Veins

Malignant melanoma rarely originates from the female nipple. Tumors that develop on the skin of the breast are often subject to a delayed diagnosis. Cytologic examination provides excellent diagnostic capabilities and is a safe procedure with a lower risk of local implantation, compared to needle or incisional biopsy. We herein report a patient who underwent surgical resection of a primary malignant melanoma of the nipple. An elastic soft nodule was observed on the left nipple, and no abnormal lesions were identified in the breast. Eventually, a malignant melanoma was diagnosed from the clinical and cytological evaluation findings. This bulky tumor was classified as a stage IIIC nodular melanoma, with a thickness of 12 mm. The patient received adjuvant chemotherapy and exhibits no evidence of recurrence 7 years after surgery.
Biopsy ; Breast ; Chemotherapy, Adjuvant ; Delayed Diagnosis ; Female ; Humans ; Melanoma* ; Needles ; Nipples* ; Recurrence ; Skin

We examined the relationship between the timing of habitual physical activities and sleep quality in older adults. The subjects were Japanese community-dwelling older adults (n=49, average age 70.1±3.5 years; men: 36.7%). We measured habitual physical activity using a 3-axis accelerometer (HJA-350 IT, Omron) for a week. Timing of physical activity was classified into the following three periods: (1) morning: waking to 11:59, (2) afternoon: 12:00 to 17:59, and (3) night: 18:00 to bedtime. We also categorized the intensity of habitual physical activity during 2 sessions as either (1) low (1.6-2.9 METs) or (2) moderate-to-vigorous (≧3.0 METs) intensity. The subjective sleep parameters were assessed using the Pittsburgh Sleep Quality Index (PSQI). We used a forced-entry multiple regression analysis to investigate the relationships between subjective sleep parameters and the timing of physical activities. Forced-entry multiple regression analysis revealed that sleep latency and PSQI global score were positively correlated with low-intensity physical activity at night. However, there was no significant correlation with moderate-to-vigorous activity. These results suggest that low-intensity habitual physical activity at night would be one useful and modifiable factor to improve sleep quality in the elderly.

Background: We evaluated the effectiveness of gemcitabine and paclitaxel therapy in patients with metastatic urothelial carcinoma for whom two lines of sequential chemotherapy had been unsuccessful.

Methods: A total number of 105 patients who had previously received first-line chemotherapy consisting of gemcitabine and cisplatin or carboplatin, were treated with second-line gemcitabine and docetaxel therapy between June 2006 and May 2015. Of these patients, 15 with an Eastern Cooperative Oncology Group Performance Status of 0 or 1 were administered gemcitabine and paclitaxel as third-line treatment from 2013 after failure of the second-line therapy. For each 21-day cycle, gemcitabine (1000 mg/m²) was administered on days 1, 8, and 15, and paclitaxel (200 mg/m²) on day 1. Patients were assessed for each cycle and any adverse events were noted. Furthermore, a Short Form Health Survey questionnaire was used to assess each patient’s quality of life.

Results: Third-line gemcitabine and paclitaxel treatment cycles were undertaken for a median of four times (range 2–9). The disease control rate was 80.0%. After second-line gemcitabine and docetaxel therapy was completed, median progression-free survival and median overall survival were determined as 9.8 and 13.0 months, respectively. The only prognostic factor for overall survival, as determined by univariate and multivariate analyses, was third-line gemcitabine and paclitaxel therapy. Neutropenia (66.7%) and thrombocytopenia (53.3%) were noted as the grade 3 treatment-related toxicities. After two cycles of third-line gemcitabine and paclitaxel therapy, the pre- and post-treatment quality of life scores did not differ significantly.

Conclusions: Results demonstrate that third-line combination therapy using gemcitabine and paclitaxel is a feasible option for metastatic urothelial carcinoma patients.

A 28-year-old woman with patent foramen ovale who developed tricuspid valve infective endocarditis with complications of multiple infarctions and abscesses was treated surgically. The patient was transferred to our institution because of fever and joint pain. Echocardiography revealed a large vegetation (25 mm) on the tricuspid valve and a patent foramen ovale. Computed tomography and magnetic resonance imaging showed cerebral infarctions, multiple lung abscesses, and vertebral osteomyelitis. Staphylococcus epidermidis was identified in blood cultures. After treatment with adequate antibiotics for 5 weeks, the patient underwent surgical resection of the vegetation followed by tricuspid valve repair and direct closure of the patent foramen ovale. Antibiotic therapy was continued postoperatively, and the patient was discharged 7 weeks after the operation. No further endocarditis or embolism has occurred. In cases of right-sided endocarditis with systemic embolism and abscesses, the presence of a patent foramen ovale should be considered, and appropriate timing of the operation should be determined to prevent further systemic embolization of the vegetation.

This study examined whether physical and cognitive function was independently associated with risk of Musculoskeletal Ambulation Disorder Symptom Complex (MADS) in community-dwelling older people. We examined 640 older people (315 men, 325 women; 65–89 years). We assessed physical performance by one-leg standing with eyes open, timed up and go (TUG), muscle strength, muscle power, and gait speed. Cognition was assessed using Mini-Mental State Examination (MMSE), Clinical Dementia Rating (CDR), and Trail-Making Tests (TMT) A and B. We divided participants by physical function into “MADS” (one-leg standing < 15s or TUG ≥ 11s) and “non-MADS”, and identified cognitive impairment if MMSE was < 27 and CDR ≥ 0.5. We also grouped by sex and age (younger-old: 65–74 years and older-old: 75–89 years), and controlled for age, Body Mass Index, education and steps. Physical and cognitive function was significantly worse in the MADS groups. The younger-old men had poorer muscle strength, muscle power and TMT-A. The younger-old women had poorer muscle power, gait speed, MMSE and TMT-B. Older-old men had poorer muscle strength, and older-old women poorer gait speed (P < 0.05). The MADS groups also had significantly higher adjusted odds ratio (OR) for cognitive impairment (younger-old men: OR: 4.62; 95% confidence interval [CI]: 1.08–19.8; younger-old women: OR: 6.09; 95% CI: 1.03–35.9; P < 0.05). This study suggested that poorer physical and cognitive function was significantly associated with the risk of MADS, and these associations may be differ with sex and age.