Feasibility of gastric endoscopic submucosal dissection in elderly patients aged ≥ 80 years

BACKGROUNDEndoscopic resection, especially endoscopic submucosal dissection (ESD), is increasingly performed in elderly patients with early gastric cancer, and lesions beyond the expanded indications are also resected endoscopically in some patients. It is essential to assess whether gastric ESD is safe and suitable for elderly patients and investigate what type of lesions carry an increased risk of ESD-related complications.AIMTo assess the efficacy and feasibility of gastric ESD for elderly patients, and define high-risk lesions and prognostic indicators.METHODSAmong a total of 1169 sessions of gastric ESD performed in Kanagawa Cancer Center Hospital from 2006 to 2014, 179 sessions (15.3%) were performed in patients aged ≥ 80 years, and 172 of these sessions were done in patients with a final diagnosis of gastric cancer. These patients were studied retrospectively to evaluate short-term outcomes and survival. The short-term outcomes included the rates of en bloc resection and curative resection, complications, and procedure-related mortality. Curability was assessed according to the Japanese Gastric Cancer Treatment Guidelines 2010. Fisher’s exact test was used to statistically analyze risk factors. Clinical characteristics of each group were compared using Fisher’s exact test and Mann-Whitney U test. Survival rates at each time point were based on Kaplan-Meier estimation. Overall survival rates were compared between patients with gastric cancer in each group with use of the log-rank test. To identify prognostic factors that jointly predict the hazard of death while controlling for model overfitting, we used the least absolute shrinkage and selection operator (LASSO) Cox regression model including factors curative/ noncurative, age, gender, body mass index, prognostic nutritional index, Charlson comorbidity index (CCI), Glasgow prognostic score, neutrophil-to-lymphocyte ratio, and antithrombotic agent use. We selected the LASSO Cox regression model that resulted in minimal prediction error in 10-fold cross-validation. P < 0.05 was considered statistically significant.RESULTSThe en bloc dissection rate was 97.1%, indicating that a high quality of treatment was achieved even in elderly patients. As for complications, the rates of bleeding, perforation and aspiration pneumonitis were 3.4%, 1.1% and 0.6%, respectively. These complication rates indicated that ESD was not associated with a particularly higher risk in elderly patients than in nonelderly patients. A dissection incision > 40 mm, lesions associated with depressions, and lesions with ulcers were risk factors for post-ESD bleeding, and location of the lesion in the upper third of the stomach was a risk factor for perforation in elderly patients (P < 0.05). Location of the lesion in the lower third of the stomach tended to be associated with a higher risk of bleeding. The overall survival (OS) did not differ significantly between curative and noncurative ESD (P = 0.69). In patients without additional surgery, OS rate was significantly lower in patients with a high CCI (≥ 2) than in those with a low CCI (≤ 1) (P < 0.001).CONCLUSIONGastric ESD is feasible even in patients aged ≥ 80 years. Observation without additional surgery after noncurative ESD is reasonable, especially in elderly patients with CCI ≥ 2.     

The role of after-hours house-call medical service in the treatment of COVID-19 patients awaiting hospital admission: A retrospective cohort study

Due to the increasing number of coronavirus disease 2019 (COVID-19) cases in Japan, hospitals are unable to provide admission and immediate inpatient care. The after-hours house call (AHHC) service offers telephone consultations and in-home care to patients awaiting admission. Currently, there is no report on the management of COVID-19 patients when inpatient beds are insufficient.We aimed to describe the clinical characteristics and outcomes of COVID-19 patients treated by an AHHC medical service in Osaka and Tokyo, between April and May 2021 (during the fourth wave in Japan). Patients were classified into 2 groups: Moderate I and Moderate II, according to the severity of infection under Japanese guidelines. A retrospective study of the hospital records and follow-up telephone consultations was performed.The AHHC treated a total of 55 COVID-19 patients (17 with Moderate I, 38 with Moderate II disease). The median ages (interquartile range) were 63 (49–80.5) and 64 (50.8–81), respectively. In each group, approximately 30% of AHHC patients received out-of-hospital oxygen therapy for the duration of their treatment until it was no longer required. Major symptoms, including shortness of breath or difficulty breathing (47.1% and 78.9%, respectively) and fever or chills (41.2% and 76.3%, respectively) were lower in the Moderate I group than in the Moderate II group. Overall, 16.4% of patients died, with 17.6% in the Moderate I group and 15.8% in the Moderate II group.We found the proportion of mortality in patients treated by the AHHC was slightly higher to that of patients treated in Japanese hospitals. This study will provide an alternative management of patients requiring oxygen in situations where hospital beds are in short supply.     

Efficacy and safety of standard of care with/without bevacizumab for platinum‐resistant ovarian/fallopian tube/peritoneal cancer previously treated with bevacizumab: The Japanese Gynecologic Oncology Group study JGOG3023

We investigated the efficacy and safety of further bevacizumab therapy in patients with platinum‐resistant ovarian cancer whose disease had progressed after bevacizumab plus chemotherapy. In this multicenter, open‐label, phase II trial (JGOG3023), patients were randomized 1:1 to a single‐agent chemotherapy alone (either pegylated liposomal doxorubicin [40 or 50 mg/m² administered intravenously], topotecan [1.25 mg/m² intravenously], paclitaxel [80 mg/m² intravenously], or gemcitabine [1000 mg/m² intravenously]) or single‐agent chemotherapy + bevacizumab (15 mg/m² intravenously). The primary endpoint was investigator‐assessed progression‐free survival (PFS) according to RECIST version 1.1. Secondary endpoints were overall survival (OS), objective response rate (ORR), and response rate according to Gynecological Cancer Intergroup cancer antigen 125 criteria. In total, 103 patients were allocated to chemotherapy (n = 51) or chemotherapy + bevacizumab (n = 52). Median investigator‐assessed PFS was 3.1 and 4.0 mo in each group, respectively (hazard ratio [HR] = 0.54, 95% confidence interval [CI]: 0.32‐0.90, P = .0082). Median OS was 11.3 and 15.3 mo in each group, respectively (HR = 0.67, 95% CI: 0.38‐1.17, P = .1556). Respective ORRs were 13.7% and 25.0% (P = .0599) and response rates were 16.7% and 21.4% (P = .8273). The incidence of grade ≥3 treatment‐related AEs was 42.0% in the chemotherapy group and 54.9% in the chemotherapy + bevacizumab group; AEs were well tolerated, with only 2 and 12 events leading to discontinuation of therapy, respectively. Bevacizumab was effective beyond progressive disease and AEs were manageable. The observed improvement in PFS requires further verification.     

Adult onset limb-girdle type mitochondrial myopathy with a mitochondrial DNA np8291 A-to-G substitution

We analyzed mitochondrial DNA (mtDNA) from 7 patients in four families with adult onset limb-girdle type mitochondrial myopathy to clarify their genetic background. The patients, 2 men and 5 women, showed common clinical features, characterized by isolated skeletal myopathy, high serum creatine kinase level, ragged-red fibers and cytochrome c oxidase-defective fibers. Analysis of muscle biopsy specimens indicated that cytochrome c oxidase activity was decreased relative to that of citrate synthase in 5 of the 7 patients. Southern blotting and direct sequence analyses showed an A-to-G homoplasmic transition at np8291 and intergenic COII/tRNA(Lys) 9bp deletion in all patients. This substitution was detected in only 2 of 600 control individuals including healthy subjects and patients with other neuromuscular disorders; these 2 individuals had diabetes mellitus and myotonic dystrophy, respectively. Consequently, the mtDNA transition at np8291 was a rare polymorphism. However, the 7 patients we studied had identical clinical, pathological, biochemical, and genetic features. Therefore, limb-girdle type mitochondrial myopathy with this rare polymorphism may form a subgroup of adult onset mitochondrial myopathy. Received: December 3, 1998 / Accepted: February 18, 1999     

Plasma and bone osteocalcin levels in rats with type ii collagen—induced arthritis

Osteocalcin levels in plasma and bone were measured by enzyme immunoassay in rats with arthritis induced by immunization with type II collagen and in untreated control rats. Compared with levels in control rats, the plasma levels of osteocalcin in arthritic rats were markedly decreased 1–3 weeks after immunization; during weeks 8–14, these levels were significantly increased. The osteocalcin content of tarsal bones changed in parallel with the plasma levels. These data suggest that osteocalcin levels in the plasma of arthritic rats reflect alterations in bone formation activity.     

Buccal hemangioma with phleboliths. Report of two cases

Two cases of buccal hemangioma with phleboliths were reported. Angiography, angioxerography, and computerized tomography were carried out before the procedures were planned. One patient was treated by means of surgical excision of the tumor after ligation of the left external carotid artery. The second patient was treated by means of surgical excision alone. Histologic examinations suggested that the thrombi in the blood vessels of hemangiomas might become the core of the phleboliths. Analysis of the phleboliths by means of x-ray diffraction and infrared spectrometry confirmed calcium phosphate and calcium carbonate as the main components of the phleboliths.