The rapid efficacy of abatacept in a patient with rheumatoid vasculitis

We report a case of rheumatoid vasculitis (RV) that responded well to abatacept, a cytotoxic T lymphocyte-associated antigen 4 (CTLA4)-immunoglobulin fusion protein. A 38-year-old woman developed RV despite treatment with methotrexate and tumor necrosis factor (TNF) inhibitors. The effects of steroid therapy, immunoabsorption plasmapheresis, and interleukin-6 inhibitor were insufficient, however, administration of abatacept rapidly improved her clinical symptoms with almost normalization of the immunological findings. This is the first published case report of the successful treatment of RV with abatacept.     

Efficacy of preoperative skin traction for hip fractures: a single-institution prospective randomized controlled trial of skin traction versus no traction

Background

Preoperative traction for hip fractures is of no benefit in semi-urgent surgery. However, its efficacy has not been assessed in cases in which emergency surgery was not possible. We evaluated the efficacy of preoperative skin traction for hip fractures in a level II trauma center in Japan where many patients undergo delayed surgery.

Methods

We undertook a randomized controlled trial. Eighty-one patients were randomized to be treated with skin traction (41 patients), or bed rest (40 patients). Preoperative pain was assessed by use of a visual analogue scale and the number of analgesics required. Fracture reduction was measured on the basis of leg-length and neck–shaft angle discrepancies on the radiograph on admission, a day before surgery, and after surgery.

Results

The mean time from admission to surgery was 7.5 days. Pain decreased markedly on the day after admission in both the traction and no-traction groups. No significant difference was found during the preoperative waiting period between the groups in either pain score or number of analgesics taken. No significant difference was found in radiographic data either before or after surgery, and satisfactory reduction was achieved after surgery irrespective of the use of skin traction.

Conclusions

In our single-institution prospective randomized controlled trial, preoperative skin traction for patients with hip fracture had no effect on pain relief before surgery or reduction of fracture displacement during surgery, irrespective of preoperative waiting time.     

Cilostazol may improve cognition better than clopidogrel in non-surgical adult patients with ischemic moyamoya disease: subanalysis of a prospective cohort

ABSTRACT

Objective: Adult patients with ischemic moyamoya disease (MMD) who receive treatment with antiplatelet drugs reportedly show improvements in neuropsychological test scores after around 2 years. The purpose of the present study subanalyzing the same patient cohort used in a previous study was to determine which antiplatelet drug, clopidogrel or cilostazol, results in better improvement of cognitive function among non-surgical adult patients showing ischemic MMD without severe hemodynamic compromise.

Methods: Sixty-six patients without cerebral misery perfusion on ¹⁵O gas positron emission tomography were treated with pharmacotherapy alone. Patients ≥50 years old and <50 years old initially received clopidogrel and cilostazol, respectively. Any patient suffering side effects of the antiplatelet drug switched to the other antiplatelet drug. Neuropsychological tests were performed at study entry and at the end of the 2-year follow-up, and differences in each neuropsychological test score between the two time points (second test score – first test score) were calculated and defined as Δ scores.

Results: Among the five neuropsychological tests, Δ scores for two tests were significantly greater in patients treated with cilostazol (n = 36) than in those treated with clopidogrel (n = 30), and Δ scores of the remaining three tests did not differ between patient groups. Based on Δ scores, 15 patients (23%) were defined as showing interval cognitive improvement. On multivariate analysis, cilostazol administration (95% confidence interval, 1.19–193.98; P = 0.0361) represented an independent predictor of interval cognitive improvement.

Conclusions: Cilostazol may improve cognition better than clopidogrel in non-surgical adult patients with ischemic MMD.     

A case of tubulocystic carcinoma of the kidney with aggressive features

Tubulocystic carcinoma of the kidney is rare and typically indolent. Our case involved an aggressive tubulocystic carcinoma as well as the radiological confirmation of its relation to papillary renal cell carcinoma. A 46-year-old male presented with renal multiloculated cysts with a solid part. On computed tomography and magnetic resonance imaging, the solid part showed the characteristics of papillary renal cell carcinoma. Contrast enhancement of the solid part was fluffy and sparse because of the coexistence of cysts. Perirenal fat invasion resulted in exophytic cysts, and renal-hilar cystic lymph node metastasis existed. The histopathological diagnosis was tubulocystic carcinoma associated with areas of papillary renal cell carcinoma and poorly differentiated carcinoma with metastasis. Our case suggests that the solid part enhancement of tubulocystic carcinoma tends to be fluffy and sparse, and exophytic cysts and cystic lymph nodes may show radiologically aggressive findings.     

Prognosis After Brain Metastasis from Differentiated Thyroid Carcinoma

Background

In patients with differentiated thyroid carcinoma (DTC), lung and bone metastasis sometimes occur. However, brain metastasis (BM) is extremely rare. Because most previous reports about BM from DTC included a relatively small number of cases, the clinical characteristics and outcomes of BM are still unclear.

Patients and methods

Between 1965 and 2013, among 961 patients who had died because of DTC, 24 patients were diagnosed with BM from DTC. One patient with BM from DTC is still alive. To identify the prognostic factors for longer survival after BM, the medical records of these 25 patients were retrospectively reviewed.

Results

The median age at BM diagnosis was 66 years. Typical symptoms associated with BM had appeared in 20 patients (80 %). The Karnofsky Performance Status (KPS) was good (≥70) in 10 patients and poor (≤60) in 15 patients. Seven patients had a single intracranial lesion of BM, 6 patients had 2 or 3 lesions, and 9 patients had 4 or more. Eleven patients did not receive any treatment for BM, and 14 patients underwent surgical resection, radiation therapy, or both. One-year and 5-year disease-specific survival rates were 28 and 10.6 %, respectively. Good KPS (≥70), small number of intracranial lesions (≤3), and treatment for BM were prognostic factors for long survival on univariate analysis (p < 0.05). On multivariate analysis, only treatment for BM was significant.

Conclusion

Treatment of BM from DTC is indicated in patients who have a good KPS and fewer intracranial lesions, and some of them may achieve long survival.