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Abstract Background Surgical resection is standard treatment for invasive intraductal papillary mucinous carcinoma (IPMC); however, impact of multidisciplinary treatment on survival including postoperative adjuvant therapy (AT), neoadjuvant therapy (NAT), and treatment for recurrent lesions is unclear. We investigated the effectiveness of multidisciplinary treatment in prolonging survival of patients with invasive IPMC. Methods This retrospective multi‐institutional study included 1183 patients with invasive IPMC undergoing surgery at 40 academic institutions. We analyzed the effects of AT, NAT, and treatment for recurrence on survival of patients with invasive IPMC. Results Completion of the planned postoperative AT for 6 months improved the overall survival (OS), disease‐specific survival (DSS), and recurrence‐free survival (RFS) of patients with stage IIB and stage III resected invasive IPMC, elevated preoperative carbohydrate antigen 19–9 level, lymphovascular invasion, perineural invasion, serosal invasion, and lymph node metastasis on un‐matched and matched analyses. Of the patients with borderline resectable (BR) invasive IPMC, the OS (p = 0.001), DSS (p = 0.001), and RFS (p = 0.001) of patients undergoing NAT was longer than that of those without on the matched analysis. Of the 484 invasive IPMC patients (40.9%) who developed recurrence after surgery, the OS of 365 patients who received any treatment for recurrence was longer than that of those without treatment (40.6 vs. 22.4 months, p

Abstract Aims Plasma volume status (PVS), a measure of plasma volume, has been evaluated as a prognostic marker for chronic heart failure. Although the prognostic value of PVS has been reported, its significance in patients with acute decompensated heart failure (ADHF) admitted to the cardiovascular intensive care unit (CICU) remains unclear. In this study, we examined the relationship between PVS and long‐term mortality in patients with ADHF admitted to the CICU. Methods Between January 2018 and December 2020, 363 consecutive patients with ADHF were admitted to the Nippon Medical School Hospital CICU. Of the 363 patients, 206 (mean age, 74.9 ± 12.9 years; men, 64.6%) were enrolled in this study. Patients who received red blood cell transfusions, underwent dialysis, were discharged from the CICU or died in the hospital were excluded from the study. We measured the PVS of the patients at admission, transfer to the general ward (GW) and discharge using the Kaplan–Hakim formula. The patients were assigned to four groups according to the quartiles of their PVS measured at each of the three abovementioned timepoints. We examined the association between PVS and all‐cause mortality during the observation period (1134 days). The primary endpoint of this study was all‐cause mortality. Results The Kaplan–Meier analysis showed that the high PVS group had a significantly higher mortality rate at admission, transfer to the GW and discharge than the other groups (log‐rank test: P = 0.016, P = 0.005 and P

Abstract Werner's syndrome is a rare progressive disorder that is characterized by a variety of clinical manifestations which mimic features of advanced ageing. Malignancy is one of the most problematic complications of Werner's syndrome. Lung cancer associated with Werner's syndrome is rare. A 54‐year‐old woman with Werner's syndrome was referred to our department because an abnormal shadow had been detected on routine chest radiography. Chest computed tomography revealed an abnormal nodule in the left upper lobe. Bronchoscopic examination revealed the presence of squamous cell carcinoma. Other imaging studies showed no metastatic lesions; therefore, the patient was diagnosed with stage IA3 squamous cell carcinoma. She underwent left upper lobectomy and lymph node dissection without major complications, and no recurrence was found for 2 years postoperatively.

Abstract Background There have been few studies of countermeasures against postoperative cholangitis, a serious complication after pancreaticoduodenectomy (PD) that impairs quality of life. Objective To evaluate our recently developed, novel method of choledochojejunostomy with a larger anastomotic diameter, the “T‐shaped anastomosis.” Methods The study included 261 cases of PD. The T‐shaped choledochojejunostomy technique was performed with an additional incision for a distance greater than half the diameter of the bile duct at the anterior wall of the bile duct and the anterior wall of the elevated jejunum. To compensate for potential confounding biases between the standard anastomosis group (n = 206) and the T‐shaped anastomosis group (n = 55), we performed propensity score matching (PSM). The primary endpoint was the incidence of medium‐term postoperative cholangitis adjusted for PSM. Results In the PSM analysis, 54 patients in each group were matched, and the median bile duct diameter measured by preoperative CT was 8.8 mm versus 9.3 mm, the rate of preoperative biliary drainage was 31% versus 37%, the incidence of cholangitis within 1 month before surgery was 9% versus 13%, and the incidence of postoperative bile leakage was 2% versus 2%, with no significant differences. The incidence of medium‐term postoperative cholangitis was 15% versus 4%, and multivariate logistic regression revealed that T‐shaped choledochojejunostomy was an independent predictor of a reduced incidence of cholangitis (odds ratio, 0.17, 95% CI 0.02–0.81; p = 0.024). Conclusions The T‐shaped choledochojejunostomy technique was shown to be effective with a significant reduction in the incidence of medium‐term postoperative cholangitis. Clinical trial identification: UMIN000050990.

Abstract Introduction The prognosis of pancreatic ductal adenocarcinoma (PDAC) in patients with positive peritoneal washing cytology (CY1) is poor. We aimed to evaluate the results of staging laparoscopy (SL) and treatment efficacy in CY1 patients based on a resectability classification. Methods We retrospectively reviewed 250 patients with PDAC who underwent SL before the initial treatment between 2017 and 2023 at the University of Toyama. Results The breakdown of cases by resectability classification was resectable (R):borderline resectable (BR):unresectable locally advanced (UR‐LA) = 131:48:71 cases. The frequency of CY1 increased in proportion to the degree of local progression (R:BR:UR‐LA = 20:23:34%), but the frequencies of liver metastasis or peritoneal dissemination were comparable (R:BR:UR‐LA = 6.9:6.3:8.5%). Most CY1 patients received gemcitabine along with nab‐paclitaxel therapy. The CY‐negative conversion rates (R:BR:UR‐LA = 70:64:52%) and conversion surgery rates (R:BR:UR‐LA = 40:27:9%) were inversely proportional to the degree of local progression. Comparing H0P0CY1 factors for each classification, patients with H0P0CY1 had significantly more pancreatic body or tail carcinoma and tumor size ≥32 mm in R patients, whereas in BR patients, duke pancreatic monoclonal antigen type 2 (DUPAN‐2) ≥ 230 U/mL was a significant factor. In contrast, no significant factors were observed in UR‐LA patients. Conclusion The CY1 rates, CY‐negative conversion rates, and conversion surgery rates varied according to local progression. In the case of R and BR, SL could be considered in patients with pancreatic body or tail carcinoma, large tumor size, or high DUPAN‐2 level. In UR‐LA, SL might be considered for all patients.

Objective Identifying factors associated with poor outcomes in patients with delirium is important for predicting prognosis. This retrospective study developed an easy and objective cognitive function measurement scale that can predict the prognosis and mortality related to delirium. Methods Fifty‐five patients aged ≥65 years and diagnosed with delirium were included. Objective data regarding attention and orientation related to time and place were extracted from their medical records during the first consultation, and in total, six points were evaluated. The patients were categorized into high and low cognitive function (LCF) groups. The severity at the first visit and 1‐week post‐treatment was evaluated using the Clinical Global Impressions‐Severity scale. Outcomes (survival or death) at 6 months from the initial visit were evaluated by reviewing medical records. Results Although the Clinical Global Impressions‐Severity score at the first visit was not significantly different between the two groups, 1 week after treatment, it was significantly lower in the high cognitive function (HCF) group than in the LCF group. Regarding the outcome (survival or death) after 6 months, the LCF group had significantly higher mortality than the HCF group. A multivariate logistic regression analysis revealed the same result (OR = 17.049, 95% CI = 2.415–120.373, p = 0.004). Conclusion A simple cognitive assessment of attention and orientation may help predict unfavorable outcomes, including mortality, in patients with delirium.

Abstract Background Nab‐paclitaxel plus gemcitabine is a standard treatment for metastatic/locally advanced pancreatic cancer. The effectiveness of neoadjuvant therapy with nab‐paclitaxel plus gemcitabine (GnP‐NAT) in patients with borderline resectable pancreatic cancer (BRPC) remains unclear. Patients and Methods This single‐arm phase II trial included 61 patients with BRPC that were treated with two cycles of GnP‐NAT, (nab‐paclitaxel 125 mg/m2 and gemcitabine 1000 mg/m2), on days 1, 8, and 15 over a 4‐week period, which comprised one cycle. The primary endpoint was overall survival time. In the absence of disease progression, patients underwent planned pancreatectomy. Results Median overall survival, the primary endpoint, was 25.2 months, and the median recurrence‐free survival was 12.3 months. The overall rate of grade 3/4 events was 73.8%. One patient, who had a history of radiation therapy for past esophageal cancer, died from exacerbation via pneumonia. The overall resection rate was 73.8% (n = 45), and the R0 resection rate was 63.9% (n = 39). Overall, postoperative complications were found in 19 patients (42%) with 24 events, and nine patients (20%) with nine events ≥ grade IIIa, based on Dindo's classification. Conclusions This protocol treatment is thought to be a feasible, safe, and promising treatment regimen, but we caution against its use in patients with a history of interstitial lung disease and/or prior pulmonary irradiation. The survival data from this study suggest the need for further investigations of GnP‐NAT efficacy in patients with BRPC, as well as prospective evaluation of adverse events. Clinical Trial Registration UMIN Clinical Trials Registry, UMIN000024154 and ClinicalTrials.gov, NCT02926183.

Abstract Endoscopic ultrasound‐guided gallbladder drainage for patients with cholecystitis and high surgical risk is commonly performed by dilating the fistula before inserting the delivery sheath; however, this carries an increased risk of peritonitis. To overcome this problem, we developed a new technique that did not require dilation, using a 0.035‐inch stiff guidewire, and retrospectively evaluated the efficacy and safety of this technique. This retrospective case series report collected data on non‐surgical patients who underwent endoscopic ultrasound‐guided gallbladder drainage for various indications at Steel Memorial Muroran Hospital between November 2020 and October 2022. A total of 71 patients were included (mean age 83 ± 7.6 years; 33 women and 38 men). Breakthrough of the delivery sheath without dilation of the fistula was successful in 97.2% (n = 69) of patients. The success rate of stent placement was 98.6% (n = 70), as was the clinical success rate. Complications occurred in 2.8% (n = 2) of patients. Early and late adverse events occurred in 2.8% (n = 2) and 12.7% (n = 9) of patients, respectively. The mean procedure time was 24.8 ± 9.3 min. If a 0.035‐inch stiff guidewire is used, the dilation procedure can be omitted in the endoscopic ultrasound‐guided gallbladder drainage using self‐expandable metal stents.

Key Clinical Message Left atrial posterior wall on the vertebra is often difficult to obtain stable tissue contact with ablation‐catheter. Laser balloon ablation is effective because the compression from the vertebra can be visualized through endoscopy. Abstract When performing pulmonary vein isolation (PVI) with radiofrequency, left atrial posterior wall on the vertebra is often difficult to obtain stable tissue contact with ablation‐catheter because of the movement of the ablation point. Laser balloon ablation is effective for the achievement of durable PVI in cases with such anatomical characteristics because the compression from the vertebra can be visualized through endoscopy.

Improving protein stability is important for industrial applications, and one promising method for achieving this is backbone circularization. As connector length affects stability, predicting and elucidating a more stable connector length is necessary for development of the backbone circularization method. However, the relationship between connector length and protein stability has not been completely elucidated. Here, we determined the most stable connector length for granulocyte colony‐stimulating factor by changing one residue at a time to produce connector length variants and then measuring their thermal stability. Analysis of the local structures obtained from the predicted structures of the circularized variants revealed that an approach using helix length, dihedral backbone angle, and number of unbonded hydrogen bond donors and acceptors is suitable for identifying connector lengths with higher stability.

ABSTRACT Introduction Few studies have examined the effects of glucagon‐like peptide‐1 receptor agonist switching, particularly in Japanese patients. Therefore, we aimed to investigate the effects of switching from liraglutide to semaglutide or dulaglutide on blood glucose, body weight, and the occurrence of adverse effects in clinical practice. Materials and Methods This was an open‐label, prospective, randomized, parallel‐group controlled trial. Patients with type 2 diabetes treated with liraglutide (0.6 or 0.9 mg) at Yokosuka Kyosai Hospital in Japan were recruited from September 2020 to March 2022 and, after obtaining informed consent, randomly assigned to the semaglutide or dulaglutide group (1:1). Changes in the glycated hemoglobin level from baseline to weeks 8, 16, and 26 were evaluated post‐treatment. Results Initially, 32 participants were enrolled, of whom 30 completed the study. Glycemic control was significantly better in the semaglutide group than in the dulaglutide group (−0.42 ± 0.49% vs −0.00 ± 0.34%, P = 0.0120). Body weight significantly decreased in the semaglutide group (−2.6 ± 3.6 kg, P = 0.0153), whereas no change was observed in the dulaglutide group (−0.1 ± 2.7 kg, P = 0.8432). We found a significant difference in body weight between the groups (P = 0.0469). The proportion of participants who reported adverse events was 75.0% and 18.8% in the semaglutide and dulaglutide groups, respectively. One patient in the semaglutide group had difficulty continuing treatment due to severe vomiting and weight loss. Conclusions Switching from once‐daily liraglutide to once‐weekly semaglutide 0.5 mg significantly improved glycemic control and body weight compared with switching to once‐weekly dulaglutide 0.75 mg.

Background. Extracellular adenosine 5′-triphosphate (ATP) acts as a signaling molecule in the peripheral nerves, regulating myelination after nerve injury. The present study examined whether the cerebrospinal fluid (CSF) ATP levels in patients with Guillain–Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP) are related to disease severity. Methods. CSF ATP levels in 13 patients with GBS and 18 patients with CIDP were compared with those in a control group of 16 patients with other neurological diseases (ONDs). In patients with CIDP, CSF ATP levels were compared before and after treatment. The correlations between CSF ATP levels and other factors, including clinical data and CSF protein levels, were also evaluated. Results. Median CSF ATP levels were significantly higher in patients with GBS and CIDP than in those with ONDs. When patients with CIDP were classified into two groups depending on their responsiveness to immunotherapy, median CSF ATP levels were significantly higher in good responders than in ONDs. CSF ATP levels tended to decrease after treatment in patients with CIDP. In patients with CIDP, there is a negative correlation between CSF ATP and CSF protein levels. Conclusions. CSF ATP levels were increased in patients with GBS and CIDP. In particular, CSF ATP levels tended to decrease following treatment in patients with CIDP. CSF ATP levels may be useful biomarkers for the diagnosis or monitoring of therapeutic effects in patients with GBS and CIDP.

Abstract Background and Aim The rate of ulcerative colitis (UC)‐related colorectal cancer (colitis‐associated carcinoma) is increasing. Estrogen receptor (ER) beta expression has been studied separately in patients with sporadic colorectal cancer and those with colitis‐associated carcinoma. However, no study has compared the expression in both of these cancer types. The present study aimed to evaluate the relationship between colitis‐associated carcinoma and ERs and assess whether the expression of ER beta influences cell proliferation. Methods This study included 45 surgically operated colitis‐associated carcinomas, 43 high‐grade dysplasias, 34 low‐grade dysplasias, 36 sporadic colorectal cancers, 44 high‐grade adenomas, and 34 low‐grade adenomas. ER beta expression was evaluated with immunohistochemistry. Results Colitis‐associated carcinoma showed significantly lower ER beta immunoexpression than sporadic colorectal lesions and high‐ and low‐grade dysplasia. In seven colitis‐associated carcinoma harboring both intensity score 3 (strong immunoexpression) and score 1 (weak immunoexpression) areas, the correlation among ER beta intensity, Ki‐67, and p21 labeling index was assessed; an area with an ER beta intensity score of 3 showed a higher Ki‐67 labeling index than that with score 1. In four out of the seven lesions, p21 labeling index was higher in the area of ER beta score 1 than in that of ER beta score 3. Conclusions The data suggest that ER beta expression is an accelerating factor in colorectal tumors. This association may be lower in colitis‐associated carcinoma than in sporadic colorectal cancer.

Abstract A 75‐year‐old woman was referred to our hospital because of a productive cough and an abnormal shadow on chest radiography. She was diagnosed as having metastatic lung adenocarcinoma harbouring ROS proto‐oncogene 1 (ROS1). First‐line therapy was instituted with entrectinib 600 mg daily, and a gradual decrease in serum sodium level was noticed on day 6, which deteriorated to Grade 3 hyponatremia on day 12. Despite a partial therapeutic response to entrectinib, she developed fatigue and dizziness, so the drug was withdrawn. The clinical findings and laboratory workup were compatible with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) due to entrectinib. The hyponatremia subsequently improved and entrectinib was resumed at a reduced dose of 400 mg daily, which has been continued to date, with no recurrence of SIADH.

Abstract Background In pancreatic ductal adenocarcinoma (PDAC), only radical surgery improves long‐term survival. We focused on surgical outcome after induction gemcitabine along with nab‐paclitaxel (GnP) and subsequent chemoradiotherapy (CRT) with S‐1 administration for unresectable locally advanced (UR‐LA) PDAC. Methods We retrospectively analyzed 144 patients with UR‐LA PDAC between 2014 and 2020. The first‐line regimen of induction chemotherapy was GnP for 125 of the 144 patients. Of the 125 patients who received GnP, 41 who underwent radical resection after additional preoperative CRT were enrolled. We evaluated the prognostic factors for this treatment strategy. Results The median length of preoperative GnP was 8.8 months, and 30 (73%) patients had normalized CA19‐9 levels. R0 resection was achieved in 36 (88%) patients. Postoperative major complications of ≥Clavien–Dindo grade IIIa developed in 16 (39%) patients. With a median follow‐up of 35.2 months, 14 (34%) patients developed distant metastasis postoperatively. Using the Kaplan–Meier method, prognostic analysis of the 41 cases revealed the 3‐y overall survival rate (OS) was 77.4% and the 5‐y OS was 58.6%. In univariate analysis, length of preoperative GnP (≥8 months), CA19‐9 normalization, and good nutritional status at operation (prognostic nutritional index ≥41.7) were significantly associated with favorable prognosis. Multivariate analysis revealed CA19‐9 normalization (hazard ratio [HR] 0.23; P = .032) and prognostic nutritional index ≥41.7 (HR 0.05; P = .021) were independent prognostic factors. Conclusion For surgical outcome after induction GnP and subsequent CRT for UR‐LA PDAC, CA19‐9 normalization and maintenance of good nutritional status during treatment until surgery were important for prolonged prognosis.

Abstract Objectives The amount of propofol required for intravenous sedation (IVS) in patients on long‐term oral benzodiazepine (BZD) therapy may be affected by drug interactions and central changes in sensitivity. However, there is no research on the effect of long‐term oral BZD use on the amount of propofol required for IVS. We aimed to clarify the difference between the total propofol dose required for IVS in patients with or without long‐term oral BZD therapy. Material and methods Among patients treated for 4 years, the total administered dose required for IVS with propofol alone and local anesthesia for the extraction of bilateral impacted mandibular wisdom teeth, was retrospectively compared between patients with continuous oral BZD use for ≥6 months (BZD group; n = 24) and those without such use (control group; n = 307). The aimed sedation level was the Ramsay sedation scale 3–4. Results The amount of propofol required for IVS was significantly lower in the BZD group compared to the control group (4.83 ± 1.30 vs. 5.91 ± 1.25 mg/kg/h, p

Abstract Aims/Introduction This study aimed to identify the clinical factors affecting postoperative residual pancreatic β‐cell function, as assessed by the C‐peptide index (CPI), and to investigate the association between perioperative CPI and the status of diabetes management after pancreatectomy. Materials and Methods The associations between perioperative CPI and clinical background, including surgical procedures of pancreatectomy, were analyzed in 47 patients who underwent pancreatectomy, and were assessed for pre‐and postoperative CPI. The association between perioperative CPI and glycemic control after pancreatectomy was investigated. Results The low postoperative CPI group (CPI

Abstract Species diversity encompasses both richness and evenness, but the interrelationship between these two aspects remains poorly understood. The long‐term dynamics of species diversity were examined in three natural secondary forests in Hokkaido, northern Japan, using permanent plot data gathered over 65–66 years after severe windthrow damage. The relationships among species diversity, species richness, and evenness were analyzed in the context of stand dynamics. Temporal trends in species diversity were unimodal‐shaped in three permanent plots, consistent with the pattern predicted by the intermediate disturbance hypothesis. Species richness and evenness increased following the windthrow, but decreased 27–37 years later in all three plots. In two plots, species diversity was closely associated with species richness and evenness at the early and late successional stages, respectively; in the other plot, species diversity was significantly related to both species richness and evenness in the later stage. The former two plots and the latter one plots differed markedly in terms of the extents of fatal tree damage caused by windthrow. Thus, windthrow severity affected the relationships among diversity, richness, and evenness as succession proceeded in these secondary forests. The tree density, species richness, evenness, and species diversity in all three plots decreased when the basal areas exceeded 18–24 m2/ha, indicating that increased competition among trees affected the temporal trends in these metrics. In conclusion, after a severe disturbance, the relationships among species diversity, richness, and evenness in secondary forests change with succession.

Abstract Mechanical insufflation‐exsufflation (MI‐E) is an effective airway clearance device for impaired cough associated with respiratory muscle weakness caused by neuromuscular disease. Its complications on the respiratory system, such as pneumothorax, are well‐recognized, but the association of the autonomic nervous system dysfunction with MI‐E has never been reported. We herein describe two cases of Guillain–Barré syndrome with cardiovascular autonomic dysfunction during MI‐E: a 22‐year‐old man who developed transient asystole and an 83‐year‐old man who presented with prominent fluctuation of blood pressure. These episodes occurred during the use of MI‐E with abnormal cardiac autonomic testing, such as heart rate variability in both patients. While Guillain–Barré syndrome itself may cause cardiac autonomic dysfunction, MI‐E possibly caused or enhanced the autonomic dysfunction by an alternation of thoracic cavity pressure. The possibility of MI‐E‐related cardiovascular complications should be recognized, and its appropriate monitoring and management are necessary, particularly when used for Guillain–Barré syndrome patients.

Abstract Objectives In recent years, many studies have reported that the presurgical nasoalveolar molding method improves the nose morphology; however, the reason for its effectiveness after surgery has never been understood. We evaluated the effect of nasoalveolar molding by comparing it with a passive orthopedic method without a nasal stent and focusing on the nostril morphology after primary cheiloplasty using various measurement methods. We then analyzed the essential factors. Materials and methods The patients involved were 31 infants with unilateral complete cleft lip and palate treated with primary cheiloplasty at the University of Tsukuba Hospital from 2004 to 2011. Of the 31 infants, 16 received nasoalveolar molding treatment and 15 received passive orthopedic treatment as controls. Photographic facial measurements were performed for all patients immediately and 7 months after primary cheiloplasty. The esthetics of the nostrils were assessed according to the left–right nostril symmetry, as measured by the Hausdorff distance, area ratio, perimeter ratio, and aspect a/u (the aspect ratio of the affected side)/(the aspect ratio of the unaffected side) ratio. In addition, the inclination of the nasal ridge was assessed using anthropometric measurements (Grc‐Grn∠midline and midline∠columellar axis). Results The area ratio, perimeter ratio, and Grc‐Grn∠midline were significantly greater in the nasoalveolar molding group immediately after surgery (p = 0.00062, 0.016, and 0.048, respectively) than in the control group. However, the Hausdorff distance and aspect a/u ratio were more favorable (p = 0.0018 and 0.0039, respectively) in the nasoalveolar molding group after 7 months. Conclusions The results of our study suggested that using nasoalveolar molding as a presurgical orthopedic treatment could improve the shape of the nasal cartilage with surgeon's corrections.

Abstract Purpose To analyze whether response to the GnRH test is a predictor of empty follicle syndrome (EFS) and to analyze independent risk factors for EFS. Methods The GnRH test results of 3765 patients from 2016 to 2018 were used to define the reference range of the GnRH test. Risk factors for EFS were estimated by multivariate logistic analysis of 5282 cycles (5247 oocyte‐retrieved cycles with GnRH agonist trigger and 35 cycles of EFS) conducted from 2016 to 2019. Results GnRH testing showed basal hormone values as follows: median LH 5.2 (95 percentile; 1.3–12.6) mIU/mL, LH 30 min 22.0 (6.8–57.1), basal FSH 7.3 (3.0–20.5), FSH 30 min 11.5 (5.1–30.4) and FSH/LH ratio 1.5 (0.6–4.1). Independent risk factors for EFS were antral follicle count (adjusted odds ratio; 0.94, 95% CI; 0.89–0.99), basal LH (0.78, 0.66–0.90), and days duration of ovarian stimulation (1.41, 1.21–1. 60). The respective thresholds were 8 for AFC, 5.0 for basal LH, and 16 days for duration. Conclusions LH 30 min values of the GnRH test did not predict EFS. Independent risk factors for EFS were AFC, basal LH and days duration of ovarian stimulation.

Abstract The purpose of this study was to reconstruct the spatial characteristics of the villages on Kikaijima Island immediately before and after World War II to examine the characteristics of these spatial characteristics within the context of the topographical situation of the villages. In this study, we clarified the commonalities and differences of the location and spatial composition of the villages by analyzing aerial photographs of all of the villages on Kikaijima Island by the US military immediately before and after World War II.

Abstract Parapharyngeal space tumors have poor subjective symptoms and often grow until diagnosed; therefore, mandibular transection may be needed to obtain a wider field of view during surgery. However, if a median lower lip incision is performed for the mandibular transection, esthetic problems occur after surgery. Here, we report two cases of parapharyngeal space tumors that were removed with a mandibular lateral segment‐osteotomy technique without median lower lip incision to avoid esthetic problems. Case 1 was a 49‐year‐old woman. She was aware of a right tonsillar swelling, and an imaging test revealed a tumor lesion 60 mm in size in the right parapharyngeal space. Case 2 was a 40‐year‐old woman with an abnormal position of the uvula, and an imaging test showed the left parapharyngeal space tumor lesion 45 mm in size. Both cases were diagnosed as a pleomorphic adenoma, and surgery under general anesthesia was performed jointly with otolaryngology and oral surgery. The incision was performed from the lower part of the right auricle to the anterior part of the submandibular area. After the tumor resection, the mandible was repositioned, fixed by plates, and the intermaxillary fixation was performed with a surgical stent. In both cases, slight paralysis of the mandibular branch of the facial nerve and the mental nerve was observed after the operation, but they were improved immediately. One year after the operation, the plates were removed. There have been no recurrences until now.

Abstract Introduction Neutrophils are crucial to antimicrobial defense, but excessive neutrophilic inflammation elicits immune pathology. Currently, no effective treatment exists to curb neutrophil activation. However, neutrophils express a variety of inhibitory receptors which may represent potential therapeutic targets to limit neutrophilic inflammation. Indeed, we previously showed that the inhibitory collagen receptor leukocyte‐associated immunoglobulin‐like receptor 1 (LAIR‐1) regulates neutrophilic airway inflammation and inhibits neutrophil extracellular trap formation. The inhibitory receptor Allergin‐1 is expressed by myeloid cells and B cells. Allergin‐1 suppresses mast cell and basophil activation, but a potential regulatory role on neutrophils remains unexplored. We aimed to demonstrate the regulation of neutrophils by Allergin‐1. Methods We examine Allergin‐1 isoform expression on human neutrophils during homeostatic (healthy donors) and chronic inflammatory (systemic lupus erythematosus patients) conditions in comparison to other circulating leukocytes by flow cytometry. To reveal a potential role for Allergin‐1 in regulating neutrophilic inflammation, we experimentally infect wild‐type (WT) and Allergin‐1‐deficient mice with a respiratory syncytial virus (RSV) and monitor disease severity and examine cellular airway infiltrate. Flow cytometry was used to confirm Allergin‐1 expression by airway‐infiltrated neutrophils in RSV infection‐induced bronchiolitis patients. Results Only the short 1 (S1) isoform, but not the long (L) or S2 isoform could be detected on blood leukocytes, with the exception of nonclassical monocytes, which exclusively express the S2 isoform. Allergin‐1 expression levels did not vary significantly between healthy individuals and patients with the systemic inflammatory disease on any interrogated cell type. Airway‐infiltrated neutrophils of pediatric RSV bronchiolitis patients were found to express Allergin‐1S1. However, Allergin‐1‐deficient mice experimentally infected with RSV did not show exacerbated disease or increased neutrophil airway infiltration compared to WT littermates. Conclusion Allergin‐1 isoform expression is unaffected by chronic inflammatory conditions. In stark contrast to fellow inhibitory receptor LAIR‐1, Allergin‐1 does not regulate neutrophilic inflammation in a mouse model of RSV bronchiolitis.

Introduction Mamushi bites are the most common venomous snakebites in Japan. The clinical course of a common mamushi bite is known, and its alarming complication and cause of death are acute renal failure due to the venom. However, reports of mamushi bites in kidney transplant recipients are lacking, and the clinical course is unknown. Case presentation A 66‐year‐old man who was bitten by a mamushi 3 years after kidney transplantation. Similar to the course of a typical mamushi bite, his severity gradually worsened to its peak 3 days after the bite, after which he turned lightly. A sufficient amount of infusion and continued immunosuppressive drugs were used to avoid acute renal failure. Conclusion Even if the mamushi bite occurs in a kidney transplant recipient, the course and management may be the same as usual by continuing the immunosuppressive drugs and a sufficient amount of infusion.

Abstract Aim Young carers (YCs) refer to children under the age of 18 who assume responsibilities that would normally be assumed by adults, such as caring for family members in need of care. In recent years, the concept of YCs has been expanding in Japan, and the government has been rapidly implementing strategies to support them. There is a need for a survey scale for YCs that uses standardized methods that can be compared internationally. Method The BBC/University of Nottingham Survey for estimating the prevalence of YCs and caring activities of United Kingdom adolescents was translated into Japanese, and its reliability and validity were tested with 313 adolescents. Moreover, the prevalence of YCs was estimated in a school‐based survey among 5000 adolescents. Results The Young Carers Scale Japanese version (YCS‐J) was acceptably reliable and valid. The original six‐factor model for caring activity in the Multidimensional Assessment of Caring Activities Checklist for Young Carers (MACA‐YC18) was supported by confirmatory factor analysis. The prevalence of YCs among 5000 adolescents in the Tokyo metropolitan area was estimated to be 7.4%, comparable to that reported in Western countries and in recent surveys in Japan using nonstandardized methods. YCs exhibited significantly higher scores for prosocial behavior and emotional symptoms than non‐YCs. Conclusions The YCS‐J, as an internationally comparable instrument, will be useful for understanding the actual situation of YCs in Japan, and to disseminate and implement support through cooperation among education, welfare, and healthcare sectors.

Introduction The efficacy of nivolumab for non‐clear cell renal cell carcinoma is still unclear. We present a rare case of metastatic papillary renal cell carcinoma remarkably responded to nivolumab but developed myeloradiculoneuropathy as immune‐related adverse event. Case presentation The patient had previously undergone radical nephrectomy for right renal mass and was diagnosed as papillary renal cell carcinoma type 2, pT3bN0M0. Three years after the first surgery, he received 3 mg/kg of nivolumab as a second‐line drug for mediastinum lymph nodes and lung metastases. With three cycles of nivolumab, the patient felt progressive weakness of the legs and received two cycles of steroid‐pulse therapy based on the diagnosis of myeloradiculoneuropathy. Although nivolumab therapy has been discontinued, the metastases show radiographic complete response at 2 years after the last nivolumab administration without any additional therapy. Conclusion Nivolumab may be a promising treatment option for non‐clear cell renal cell carcinoma such as papillary renal cell carcinoma.

Introduction Ileal ureteral replacement is one of the treatment options for long ureteral strictures. Most ileal ureteral replacements anastomose the distal side of the ileal segment directly to the bladder. We have reported here an initial case of laparoscopic ileal ureteral replacement for preserving the natural anti‐reflux system. Case presentation A 29‐year‐old male presented with right flank pain, and his imaging results revealed multiple strictures of the right upper‐middle ureter. Hence, we performed a laparoscopic ileal ureteral replacement surgery. The normal distal ureter was preserved, and the distal side of the ileal segment was anastomosed to it. As such, the natural anti‐reflux system could be completely preserved. Following this, the renal function was maintained, and no urinary tract infection was recorded. Conclusion Laparoscopic ileal ureteral replacement, which preserves the natural anti‐reflux system, can be considered as a treatment option for refractory upper‐middle ureteral strictures.

Abstract Dynamic digital radiography (DDR) is a motion‐detecting technique with high temporal resolution. Flexible laryngoscopy is a common modality for the observation of the larynx; however, it generates aerosol. DDR is an easy and less risky screening test for the diagnosis of recurrent laryngeal nerve paralysis during the COVID‐19 pandemic.

Abstract Thyroglossal duct on the dorsum of the tongue in the pediatric patient can cause a difficult airway due to the large mass and risk of airway obstruction associated with a swollen tongue after surgery.

Abstract McKittrick–Wheelock syndrome (MWS) is a rare entity that has been described as electrolyte and fluid depletion secondary to secretory diarrhea caused by a large villous tumor in the colon or rectum. Most tumors associated with MWS are large but benign villous adenomas. Advanced cancers are seldom reported. We report a rare case of advanced rectal cancer with multiple liver and bone metastases presenting with MWS. A 59‐year‐old man was admitted to our hospital with a more than 3‐year history of chronic mucous diarrhea. Laboratory data revealed hyponatremia, hypokalemia, hypochloremia, and renal failure. Based on the findings on colonoscopy, computed tomography, and magnetic resonance imaging, he was diagnosed with advanced rectal cancer with liver and bone metastases, and MWS. Following intravenous fluid treatment, abdominoperineal resection of the rectum with lymph node dissection was performed. The surgically resected specimen was a circumferential villous tumor measuring 110 × 80 mm. Histological examination of the resected specimens revealed signet ring cell carcinoma with villous adenoma and metastasis in regional lymph nodes. The renal dysfunction and electrolyte abnormalities that were present before surgery improved. Two courses of capecitabine were administered as adjuvant chemotherapy after the surgery. However, approximately 2 months after surgery, he died of poor general condition due to progression of the liver metastases.

Abstract Aim Right‐half dissection of the superior mesenteric artery (SMA) nerve plexus in pancreatoduodenectomy for pancreatic cancer was initiated to accomplish R0 resection; however, subsequent refractory diarrhea was a major concern. This study aimed to evaluate the necessity of this technique. Methods From April 2014 to June 2018, 74 patients with pancreatic head cancer were randomly allocated to either Group A, in which right‐half dissection of the SMA nerve plexus was performed (n = 37), or Group B, in which total preservation of the nerve plexus was performed (n = 37). Short‐term, long‐term, and survival outcomes were prospectively compared between the groups. Results The patient demographics, including the R0 resection rate, were not significantly different between the groups. Postoperative diarrhea occurred in 26 (70.3%) patients in Group A and 18 (48.6%) patients in Group B. There was a tendency for the development of severe diarrhea in Group A within 1 year postoperatively, and the frequency of diarrhea gradually decreased within 2 years, although that did not affect tolerance to adjuvant chemotherapy. There was no difference in either locoregional recurrence (27.0% vs 32.4%) or systemic recurrence (46.0% vs 46.0%). The median overall survival time in Groups A and B was 37.9 and 34.6 months, respectively (P = 0.77). Conclusion We did not demonstrate a clinical impact of right‐half dissection of the SMA nerve plexus on locoregional recurrence or survival. Therefore, the prophylactic dissection of the SMA nerve plexus is unnecessary given that refractory diarrhea could be induced by this technique (UMIN000012241).

Abstract This clinical image presents a report on the diagnosis and treatment of anti‐NMDAR encephalitis, a rare disease. This report emphasizes the importance of a differential diagnosis for acute psychiatric symptoms. Accurate and timely diagnosis is critical for the selection and implementation of treatment and for optimal patient outcomes.