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[Objectives] This study aimed to identify factors related to the practical utilization of community health needs assessment (CHNA) models that public health nurses (PHNs) learned in their fundamental education. [Design] A nationwide questionnaire survey was conducted via postal mail. [Sample] We randomly selected 630 public health institutes in Japan. The participants were 3397 full-time novice and mid-level PHNs. [Measurements] The questionnaire included the participants’ basic personal information, six items regarding the perception of CHNA with a 4-point Likert scale, learned models in their undergraduate education, their utilization in practical settings, and the reasons for their answer in narrative form. [Results] There were 951 valid responses. The results of logistic regression showed that the significant positively factors with model utilization were perception of CHNA as “not troublesome” or “not impossible as they learned, ” continuing education with 5 years of experience, and identification of the learned model in continuing education. Furthermore, the results of text mining showed the reasons for non-utilization of the model included being “busy” and having a lack of “opportunity.” [Conclusions] This study showed the associated factors with rare utilization of a learned model for PHNs. These findings may suggest improvement of continuing education and development of an appropriate assessment model.

An 84-year-old woman visited our hospital for dyspnea due to right pleural effusion, with lymphocytic dominance and a high adenosine deaminase (ADA) level, that had been noted 1 month earlier. She was suspected of having tuberculosis pleurisy; however, anti-tuberculosis treatment yielded no improvements. She was diagnosed with pleural effusion due to primary Sjögren's syndrome (SjS) based on her dry eyes and mouth, positivity for anti-Sjögren's-syndrome-related antigen A/B, and histopathologic findings of a lip biopsy and thoracoscopic pleural biopsy. Her symptoms improved after starting steroid therapy. Cases of pleural effusion due to SjS with a high ADA level may be misdiagnosed as tuberculosis pleurisy.

In a patient with a history of cancer, distinguishing a metastasis of the prior tumour from a new primary tumour relies on the comparison of morphological features between the tumour of concern and the prior tumour, often with the aid of immunohistochemistry. This approach is the basis of pathological diagnosis, but recent advances in precision cancer medicine and cancer treatments change the situation. We here present a case report of lung cancer, mimicking primary lung adenocarcinoma, with minute foci of metastatic thyroid papillary carcinoma, in a 34-year-old man with a history of papillary thyroid carcinoma. Through the analysis of thyroid tumor and lung tumor at the age of 4 and 34 years in this patient, identical NCOA4-RET translation suggested histological conversion, which was induced probably due to high selective pressure by the treatment. As histological transformation of non-small cell lung cancer is well documented as a form of recurrence after EGFR-tyrosine kinase inhibitor treatment, the lineage conversion in association with effective treatments may be a diagnostic pitfall in the era of precision cancer medicine.

[Background and Aims] Multiple developments of squamous dysplasia and squamous cell carcinoma (SCC) in the upper aerodigestive tract have been explained by field cancerization phenomenon and were associated with alcohol and cigarette use. Second primary SCC development after curative treatment impairs patients’ quality of life and survival; however, how these consumption and cessation affect field cancerization is still unknown. [Methods] This is a multicenter cohort study including 331 patients with superficial esophageal SCC (ESCC) treated endoscopically and pooled data from 1022 healthy subjects for comparison. Physiological condition in the background esophageal mucosa was classified into 3 groups based on the number of Lugol-voiding lesions (LVLs) per endoscopic view: grade A, 0; grade B, 1–9; or grade C, ≥10 LVLs. Lifestyle surveys were conducted using a self-administered questionnaire. Patients were counseled on the need for alcohol and smoking cessation by physicians and were endoscopically surveyed every 6 months. [Results] LVL grades were positively associated with alcohol drinking intensity, flushing reactions, smoking, and high-temperature food and were negatively associated with eating green and yellow vegetables and fruit. Second primary ESCC and head/neck SCC were significantly more prevalent in the grade C LVL (cumulative 5-y incidences 47.1%, 95% confidence interval [CI] = 38.0–57.2 and 13.3%, 95% CI = 8.1–21.5, respectively). Alcohol and smoking cessation significantly reduced the development of second primary ESCC (adjusted hazard ratios 0.47, 95% = CI 0.26–0.85 and 0.49, 95% CI = 0.26–0.91, respectively). [Conclusion] Alcohol drinking, smoking, flushing reaction, and high-temperature food were closely associated with field cancerization, and cessation of alcohol and smoking significantly reduced the risk of development of second primary cancer. UMIN Clinical Trials Registry ID:UMIN000001676.

To develop preoperative models as a guide to indications for neoadjuvant chemotherapy (NAC) and regional lymph node dissection (LND) before and at radical nephroureterectomy (RNU), respectively, in patients with non-metastatic upper tract urothelial carcinoma (UTUC) by incorporating the systemic immune-inflammation index (SII).This retrospective study enrolled 103 consecutive patients with UTUC undergoing RNU. The SII was calculated as neutrophils × platelets / lymphocytes. Multivariable Cox proportional hazard model was used to develop preoperative models for cancer-specific survival (CSS) and overall survival (OS). A model for predicting muscle invasion was developed using logistic regression analysis. Harrell's concordance-index (c-index) or the area under the receiver operating characteristic curve (AUC) was used to evaluate the accuracy of the models.During follow-up (median: 41 months), 26 and three patients died of UTUC and other causes, respectively. Performance status 0, clinical tumor (cT) stage ≥ 3, and SII 520 were independent adverse prognosticators for CSS, and one point was assigned to each prognosticator. Risk score models comprising the sum of the points stratified patients into three risk groups (0, 1, and 2-3; P 0.001 for CSS and OS) with respective c-indices of 0.843 and 0.820. SII 677 and ≥ cT3 were independently associated with muscle invasion. A model based on these variables predicted muscle invasion with AUC of 0.804.Preoperative SII is significantly associated with worse survival outcomes and muscle invasion in patients with non-metastatic UTUC. Our preoperative predictive models may serve as a guide to indications for NAC and LND.

[Purpose] Understanding the neuromuscular cooperativeness functions when an athlete is fatigued is essential in preventing sports injuries and examining post-injury return standards. This study aimed to investigate the kinds of changes in neuromuscular cooperativeness before and after fatigue loading. [Participants and Methods] Fifteen female university athletes were examined for chronological changes in neuromuscular cooperativeness. Muscle fatigue loading was performed using BIODEX (180°/s) during knee flexion and extension exercises on one side. Surface electromyography of the rectus femoris and biceps femoris was performed on both sides before and immediately, 5 min, 10 min, and 15 min after loading. The switching silent period and pre-motor time were calculated from the electromyographic waveforms to indicate neuromuscular cooperativeness. [Results] The switching silent periods in the loading side immediately and 5 min after loading were significantly prolonged compared with that before loading. [Conclusion] Muscle fatigue loading instantaneously prolonged the switching silent period and decreased the neuromuscular cooperativeness. Furthermore, recovery generally occurred within 10 minutes after loading.

Objectives Several preclinical data proposed a potential efficacy of osimertinib, a third-generation EGFR tyrosine kinase inhibitor, for EGFR exon 20 insertion (EGFR ex20ins)-positive non-small cell lung cancer (NSCLC). However, reported case series and a retrospective study proposed controversial efficacy. The efficacy of osimertinib in EGFR ex20ins-positive NSCLC have not been well evaluated in prospective clinical trials. In this study, we performed a prospective, single-arm, multi-center, open-label, non-randomized phase I/II study to evaluate efficacy of osimertinib for EGFR ex20ins-positive NSCLC. Materials and methods From August 2018 to January 2020, 14 NSCLC patients with EGFR ex20ins were enrolled, of whom 2 were excluded because they did not meet the inclusion criteria. Efficacy and safety of 80 mg osimertinib were evaluated. In addition, we performed a translational exploratory study to clarify the association of mutation type-specific drug sensitivity, osimertinib pharmacokinetic data, and clinical efficacy. Results Of the evaluated patients, none experienced objective response, 7 experienced stable disease (58.3%), and 5 experienced disease progression (41.7%). The median progression free survival (PFS) was 3.8 months, and the median overall survival was 15.8 months. Interestingly, the exploratory study demonstrated statistically significant positive correlation between plasma osimertinib concentration/in vitro IC50 ratio and PFS (R = 0.9912, P = 0.0001), highlighting the mutation type-specific concentration-dependent efficacy of osimertinib for EGFR ex20ins-positive NSCLC. Conclusions Regular dose, 80 mg/day, of osimertinib has limited clinical activity in NSCLC patients with EGFR ex20ins. The translational study proposed the potential efficacy of higher dose osimertinib in a subgroup of EGFR ex20ins-positive NSCLC.

PURPOSE To appropriately adopt the organ preservation approach, including subsequent chemoradiotherapy (CRT) in patients who respond to neoadjuvant chemotherapy (NAC), the distribution of residual disease, including pathological lymph nodes (LNs) and recurrence site, needs to be recognized preoperatively. This study was designed to evaluate whether endoscopic response evaluation can predict residual tumor distribution. METHODS Patients with esophageal squamous cell carcinoma who underwent transthoracic esophagectomy (TTE) were retrospectively reviewed. Endoscopic responder (ER) to NAC was defined according to primary tumor endoscopic findings. Recurrence-free survival (RFS), overall survival (OS), and residual tumor patterns were compared between groups. RESULTS Of 193 patients, 40 (20%) were classified as ER. ERs showed significantly better RFS and OS. The pN location was found within the primary tumor and cN field in 88% of ERs, which was significantly higher than non-ERs at 63% (p = 0.004). Furthermore, the postoperative recurrence incidence in the distant organ was significantly lower in the ERs than the non-ERs (8%, 32%, respectively, p = 0.002). Residual disease, including postoperative initial recurrence, existed within the same field as the primary tumor and cN in 88% of ERs, significantly higher than 42% in the non-ERs (p < 0.001). CONCLUSIONS Endoscopic response evaluation can preoperatively predict distribution of residual tumors after NAC, which could help radiation field selection in subsequent definitive CRT when patients prefer to omit TTE. Along with improvements in NAC response rate, this could facilitate organ preservation in patients who respond to NAC.

In the gynecological literature, a limited number of studies have reported intraperitoneal bleeding due to abdominal blunt trauma. In this report, we describe a rare case of massive intraabdominal hemorrhage from the uterine artery triggered by a fall injury without apparent abdominal bruising in the presence of severe endometriosis and a uterine fibroid. A 28-year-old woman who fell from a railway platform was transported to an emergency hospital. Although she did not sustain abdominal bruising and initially had no abdominal symptoms, she complained of gradually worsening abdominal pain. Abdominal CT identified intraabdominal massive hematoma, and emergency exploratory laparoscopy revealed active bleeding from the right uterine artery eroded by endometriosis, which was treated with laparoscopic electrocoagulation. The cause of the intraabdominal bleeding was associated with avulsion of the endometriosis adhesion between the right perimetrium and the right uterine artery due to inertial forces of the uterus during the fall injury. A uterine fibroid discovered during laparoscopy was suspected to strengthen the inertial forces of the uterus. In the case of hemoperitoneum after trauma, gynecological sources of bleeding must be kept in mind, especially for patients with a known history of fibroids or endometriosis.

The prognosis of patients with connective tissue disease (CTD) has improved significantly in recent years, but interstitial lung disease (ILD) associated with connective tissue disease (CTD-ILD) remains a refractory condition, which is a leading cause of mortality. Because it is an important prognostic factor, many observational and interventional studies have been conducted to date. However, CTD is a heterogeneous group of conditions, which makes the clinical course, treatment responses, and prognosis of CTD-ILD extremely diverse. To summarize the current understanding and unsolved questions, the Japanese Respiratory Society and the Japan College of Rheumatology collaborated to publish the world's first guide focusing on CTD-ILD, based on the evidence and expert consensus of pulmonologists and rheumatologists, along with radiologists, pathologists, and dermatologists. The task force members proposed a total of 27 items, including 7 for general topics, 9 for disease-specific topics, 3 for complications, 4 for pharmacologic treatments, and 4 for non-pharmacologic therapies, with teams of 2-4 authors and reviewers for each item to prepare a consensus statement based on a systematic literature review. Subsequently, public opinions were collected from members of both societies, and a critical review was conducted by external reviewers. Finally, the task force finalized the guide upon discussion and consensus generation. This guide is expected to contribute to the standardization of CTD-ILD medical care and is also useful as a tool for promoting future research by clarifying unresolved issues.

Objectives Periodontal bacteria that have been studied show a strong connection to various vascular diseases. Among the many kinds of periodontal bacteria, Porphyromonas gingivalis (Pg) is well examined in the general aspects and in a rat model. However, whether other periodontal bacteria work or react differently is not studied well. Material and methods We chose Aggregatibacter actinomycetemcomitans (Aa) and Prevotella intermedia (Pi) as different types of periodontal bacteria. Low‐density and high‐density bacterial solutions were injected in the small artery of rats' groins using our rat model. Eighteen limbs of 9 SD male rats (500–650 g) were used. After 7 days, 14–18 days, and 28 days, the rats were sacrificed. A pathological and an immuno‐histochemical study was conducted and reported on the low‐density group with 12 limbs because the Pi group lacked a high‐density study. Immuno‐histochemical staining of live Pg was performed on three limbs of three rats at 1 h, 3 h, and 1 week after injection. Results The appearances from the acute, at 7 days, to chronic phases, at 28 days, were observed. The differences of the species were certainly observed in the internal elastic lamina (IEL), and immuno‐histochemical reactions. The inflammatory reactions, such as cellular distribution or intra‐thrombus materials, were similar in all. One week later, we could not see any living bacteria in the specimen or immunological observation. Conclusions The three species were essentially the same, except for Aa's stronger disruption of IEL, and more CD3 (Pan T cell) in Pi and more CD79a (Pan B cell) in Pg. We propose a new concept of a possible mechanism of vascular diseases, in which the work of LPS (lipopolysaccharides) and a toll‐like receptor (TLR) is emphasized.

Background This study aimed to investigate the effects of metformin on gingival wound healing in insulin-resistant prediabetes. Methods C57BL/6J mice were fed normal diet (ND) or high-fat diet (HFD) for 10 weeks; half of the HFD mice were treated with metformin (HFD+Met) for the last 2 weeks. Insulin and glucose tolerance tests were performed. The palatal gingiva (2.0×0.5 mm) was surgically removed adjacent to the maxillary molars. Post-surgical wound closure was histomorphometrically evaluated for 1 week. The mRNA expression of vascular endothelial growth factor (VEGF) and endothelial nitric oxide synthase (eNOS) in the tissue were quantified by real-time polymerase chain reaction. In vitro, the proliferation and migration of human gingival fibroblasts (HGFs) cultured under high-glucose or control conditions with/without metformin were analyzed. Akt phosphorylation and VEGF expression following the insulin stimulation were evaluated with/without metformin in high-glucose or control media. Results HFD mice showed significantly higher plasma glucose levels and insulin resistance than ND mice. Gingival wound healing was delayed in HFD group compared with ND group but significantly improved in HFD+MET group. The decreased expression of VEGF and eNOS in HFD group was significantly elevated in the HFD+MET group. The proliferation and migration of HGFs were significantly impaired in high-glucose conditions compared with control; metformin treatment partially attenuated these effects. Metformin treatment significantly recovered the downregulated Akt phosphorylation and VEGF expression in high-glucose conditions. Conclusions Metformin improved delayed gingival wound healing in insulin-resistant prediabetes by accelerating HGFs proliferation and migration via Akt phosphorylation in insulin signaling pathway. This article is protected by copyright. All rights reserved.

AIM We investigated effects of direct-acting antiviral (DAA)-induced sustained virological response (SVR) after liver resection in patients with hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) for postoperative recurrence and survival. METHODS Surgical outcomes in 18 patients with postoperative DAA-induced SVR (HCC-DAA group) were compared with those in 23 patients with preoperative DAA-induced SVR (DAA-HCC group) and those in 10 patients who did not receive DAA therapy (control group). Patients who received DAA therapy >1 year after surgery and those with recurrence

Objectives To examine the effects of qigong interventions on sleep disturbance-related symptom clusters for cancer patients and to explore the possible mediating role of fatigue and depression in affecting sleep. Methods In this systematic review and meta-analysis, a systematic search was conducted through October 2020 by searching multiple English and Chinese databases. Inclusion was limited to randomized controlled trials that measured the effect of qigong on sleep and fatigue/depressive symptoms in cancer patients. Eleven studies involving 907 cancer patients were included in the systematic review, whereas the meta-analysis included ten studies with 851 cancer patients. Results The most commonly investigated form of qigong was Taichi, and the intervention length ranged from 10 days to 6 months. All studies employed self-reported measurements. Overall, qigong significantly improved sleep (SMD = −1.28, 95% CI: −2.01, −0.55) and fatigue (SMD = −0.89, 95% CI: −1.59, −0.19) in cancer patients post-intervention, but not depressive symptoms (SMD = −0.69, 95% CI: −1.81, 0.42). Notably, the benefits on sleep and fatigue became non-significant after 3 months. Qigong's effect on sleep was significantly mediated by its effect on fatigue (β = 1.27, SE = 0.24, p = 0.002), but not depressive symptoms (β = 0.53, SE = 0.26, p = 0.106). Conclusions Qigong can be recommended for improving sleep disturbance-fatigue symptom clusters in the cancer population, while qigong's benefit on sleep is likely based on its effect on reducing fatigue. Future qigong studies should adopt more rigorous design and employ strategies to maintain longevity of intervention benefits.

Background Fibroblast growth factor (FGF)‐23 is increased first in the sequence of changes associated with chronic kidney disease (CKD)‐mineral and bone disorder. Thus, its measurement may serve as a predictive indicator of incident hyperphosphatemia. Objectives To investigate whether serum FGF‐23 concentration in normophosphatemic dogs with CKD is associated with the risk of the subsequent development of hyperphosphatemia and CKD progression. Animals Forty‐two normophosphatemic dogs with CKD. Methods Blood samples and medical records were retrospectively investigated. Hyperphosphatemia was defined as a serum phosphorous concentration >5.0 mg/dL. Progression was defined as a >1.5‐fold increase in serum creatinine concentration. The time periods and hazard ratios for these outcomes were assessed using Kaplan‐Meier analysis, log‐rank test, and univariate Cox regression analysis. The variables associated with the outcomes in the univariate analysis were included in the multivariate Cox regression model with backward selection. Results Serum FGF‐23 concentration >528 pg/mL was associated with a shorter time to development of hyperphosphatemia (P

Aim This study aimed to evaluate the indications of laparoscopic repeat liver resection (LRLR) for recurrent hepatocellular carcinoma from the viewpoint of its difficulty. Methods One hundred and one patients who underwent LRLR and 59 patients who underwent open repeat liver resection (ORLR) were included. The difficulty was classified according to the preoperative predictive factors for difficult LRLR, including an open approach during previous liver resection, history of two or more previous liver resections, history of previous major liver resection, tumor near the resected site of the previous liver resection, and intermediate or high difficulty with the difficulty scoring system. We compared the surgical outcomes between the LRLR and ORLR groups based on the difficulty class (low‐ or intermediate difficiulty class, 0 to 3 predictive factors; high difficiulty class, 4 or 5 factors). Results In the low‐ or intermediate difficiulty class, intraoperative blood loss and the proportion of patients with postoperative complications were significantly lower in LRLR than in ORLR, and the duration of the postoperative hospital stay was significantly shorter in LRLR than in ORLR. In the high difficiulty class, total operative time and operative time before starting hepatic parenchymal resection were significantly longer in LRLR than in ORLR, and there were no significant differences in other surgical outcomes between the two groups. Conclusion LRLR is recommended for patients in the low or intermediate difficulty class. However, LRLR does not have an advantage with longer operative time for patients in the high difficulty class compared with ORLR., Laparoscopic repeat liver resection (LRLR) is recommended for patients in our suggested low or intermediate difficulty class. On the other hands, LRLR does not have an advantage with longer operative time for patients in the high difficulty class, compared with open repeat liver resection.

Purpose To determine the influence of a patient education and care program on the quality of life (QOL) of female patients undergoing non‐assisted reproductive technology (ART) fertility treatment. Methods Participants completed the MOS 36‐Item Short‐Form Health Survey and fertility QOL (FertiQoL) questionnaires at baseline and at 3, 6, and 12 months of treatment. The responses of patients who underwent three sessions of the program (at baseline, 3 months, and 6 months of treatment) were compared with those of patients who did not receive the program. Results This study compared 69 patients who received an additional care program with 104 patients in the control group, all from 13 facilities. Treatment FertiQoL responses (p = 0.004) and treatment tolerability (p = 0.043) differed between the program and control groups at 3 months using the repeated measures mixed model. The cost of treatment per pregnancy was lower in the program group than in the control group. Conclusion The patient education and care program provided by reproductive fertility specialists or fertility nurses during non‐ART fertility programs improves patient satisfaction.

Background It remains uncertain whether an increase in the tibial slope leads to better flexion in posterior-stabilized (PS) total knee prostheses. Purpose To compare the intra-operative flexion angle between standard and an additional 10° posterior slope inserts. Patients and methods Between December 2014 and February 2015, 22 patients (25 knees) who underwent PS mobile-bearing primary total knee arthroplasty (TKA) were included. Flexion angles were measured using either standard or specially-made inserts. Differences in flexion angles between the two situations were analyzed to determine the relationship between changes in flexion angle and pre-operative flexion angle or body mass index (BMI), and between intra- and post-operative flexion angle. Results The difference between the average flexion angle of standard inserts and specially-made inserts was not statistically significant. Although the correlations between changes in flexion angle due to insert difference and flexion angle, pre-operative flexion angle or BMI were not significant, there was a positive correlation between intra-operative and post-operative flexion at 2 years. Conclusion The results showed an additional posterior tibial slope by 10° did not affect the intra-operative flexion angle. Surgeons performing PS mobile-bearing TKA do not need to excessively slope the tibial bone cutting to improve the post-operative flexion angle. Level of evidence I, Experimental study.

Xanthogranulomatous pancreatitis (XGP) is extremely rare, with only 31 cases reported in the English literature to date. We reviewed previously reported 17 articles about XGP and report an additional case of XGP. This is the first case of XGP with xanthogranulomatous cholecystitis accompanied by intraductal papillary mucinous carcinoma (IPMC) in an 80-year-old woman. She was referred to our hospital with jaundice and general malaise and was found to have a cystic mass at the pancreatic head and a solid mass at the pancreatic tail, with dilation of both the main pancreatic duct and biliary tract noted on computed tomography. Diagnosis of IPMC at the pancreatic head with neuroendocrine tumor at the pancreatic tail was made, and the patient underwent subtotal stomach-preserving pancreatoduodenectomy with enucleation of the mass at the tail. Pathological examination revealed IPMC with xanthogranulomatous changes around the IPMC and at the pancreatic tail and gallbladder. Xanthogranulomatous pancreatitis could be induced by inflammatory reaction due to obstruction of the pancreatic duct and biliary tract by mucin produced in the IPMC. It is sometimes difficult to preoperatively differentiate XGP from malignant pancreatic tumors, such as pancreatic carcinoma or neuroendocrine tumor, using imaging studies.

Aims The impact of periodontal inflammation on lipid metabolism is controversial. This study aimed to investigate the association between full-mouth periodontal inflammation and serum lipid levels. Materials and methods In this cross-sectional study, we performed periodontal and bacteriological examinations during medical checkup on 131 subjects. The association between the periodontal inflamed surface area (PISA) and the lipid markers was analyzed by multiple linear regression, adjusting for age, sex, smoking, and body mass index. Results Overall, 118 medically healthy participants were analyzed. The proportions of none, mild, moderate, and severe periodontitis were 37.3%, 32.2%, 25.4%, and 5.1%, respectively. Multivariate analysis showed that high-density lipoprotein cholesterol was significantly higher in participants with the lowest tertile of PISA values (PISA low, coefficient: 7.94; 95% confidence interval [CI]: 1.63, 14.26, p = .01) compared to those in other tertiles (PISA high). Low-density/high-density lipoprotein cholesterol and total/high-density lipoprotein cholesterol ratios were significantly lower in the PISA-low group than the PISA-high group (coefficient: -0.26 and -0.30; 95% CI: -0.50, -0.02, and -0.59, -0.0002; p = .04 and .0498). Serum high-sensitivity C-reactive protein level, but not serum Porphyromonas gingivalis antibody titer, partly explained the association between PISA and high-density lipoprotein cholesterol. A significant interaction between female sex and PISA values toward high-density lipoprotein cholesterol level was detected. Conclusion Periodontal inflammation was inversely associated with higher high-density lipoprotein cholesterol, especially in females. Elevated serum C-reactive protein partly explained this association.

A 60-year-old Japanese woman was admitted to our hospital with a fever and shortness of breath occurring immediately after using hairspray. Chest high-resolution computed tomography (HRCT) showed ground-glass opacities (GGOs) predominantly distributed around the bronchovascular bundles, and a pathological evaluation by a transbronchial lung cryobiopsy (TBLC) revealed fibrotic non-specific interstitial pneumonia (f-NSIP). Her symptoms disappeared without the use of corticosteroids, and GGOs on HRCT improved markedly over time. This case suggests that a pathological evaluation by a TBLC for lung injury due to inhalation pathogen exposure may provide a more accurate diagnosis and a better understanding of the pathology from bronchial to interstitial lesions than transbronchial lung biopsy.

Despite the recently increasing number of elderly patients undergoing liver resection, the impact of advancing age on postoperative infections (PIs) incidence and risk remains unclear. This study aimed to investigate the impact of advancing age on PIs incidence and status. This retrospective study included 744 patients undergoing liver resection without biliary reconstruction or combined resection of other organs. Multivariable analysis with a restricted cubic spline was used to evaluate the impact of advancing age on PIs and to determine its association with PIs risk in patients undergoing open and laparoscopic liver resection (OLR and LLR, respectively). Multivariable analysis demonstrated that advancing age was significantly associated with increased PIs risk (P = 0.017). The spline curve showed that the odds ratio for PIs sharply increased starting approximately at 65 years of age. Unadjusted restricted cubic splines assessing the subcategories of PIs demonstrated that advancing age was associated with increased risks of organ/space surgical site infection and sepsis (P = 0,064 and 0.048, respectively). Multivariable analysis revealed that LLR was associated with the lower PIs risk compared with OLR (P = 0.025), whereas the lower PIs risk with LLR was not significantly obscured by advancing age (P = 0.29). Advancing age was associated with increased risk of PIs, including organ/space surgical site infections and sepsis, after liver resection especially in patients aged ≥ 65 years.

Aims To investigate the number of bed transfers (patient transfers within the same ward) and their reasons in acute care wards of mid-sized hospitals with multibed and private rooms. Background Bed transfers, even when necessary, are burdensome for patients; however, the reasons for bed transfers in various types of rooms remain unclear. Methods An observational study was conducted in seven wards in three hospitals in Japan. Nurses completed a questionnaire regarding each bed transfer, which elicited the reasons for the transfer. We classified transfer patterns based on the functions of the patients' rooms and the number of beds in each room and analyzed scores. Results Overall, 560 responses were analyzed. The average number of bed transfers per day was 2.7. In total, 43% of bed transfers were conducted for patients aged over 70. The most frequent bed transfer pattern was "transfer between patient rooms with the same number of beds" and the most frequent reason was "patient did not need that bed." Conclusions Unnecessary bed transfers could be reduced by ward designs that reflect nurses' clinical judgment. Implications for nursing management Monitoring data for the reason regarding bed transfer contributes to hospital planning and decreases unnecessary bed transfers.

The optimal dosage of methotrexate (MTX) for graft-versus-host disease (GVHD) prophylaxis after cord blood transplantation (CBT) has not been well elucidated. Therefore, we conducted a retrospective study comparing a mini-MTX group (5 mg/m2 on day 1, 3 and 6) to a short-MTX group (10 mg/m2 on day 1 and 7 mg/m2 on day 3 and 6) after CBT. Sixty-three patients were classified as the mini-MTX group and 20 as the short-MTX group. The median time and cumulative incidence of neutrophil engraftment did not vary between the two groups. The cumulative incidence of grade 2–4 and grade 3–4 acute GVHD was similar in both groups. Overall survival in the mini-MTX group was significantly lower than in the short-MTX group (46.9% vs. 88.7% at 1 year, p

Objective To explore the prognostic role of the controlling nutritional status score in patients with metastatic renal cell carcinoma. Methods We retrospectively analyzed 107 patients with metastatic renal cell carcinoma who received their diagnosis between 2007 and 2018 and were treated with or without a first-line interferon or tyrosine kinase inhibitor at a single cancer center. The controlling nutritional status score was based on values for albumin, lymphocyte count and total cholesterol at the metastatic renal cell carcinoma diagnosis. Association of the controlling nutritional status score and clinical variables, including the Memorial Sloan-Kettering Cancer Center and the International Metastatic Renal Cell Carcinoma Database Consortium risk classifications, with overall survival was examined using the Cox proportional hazard model. Predictive accuracy of the prognostic factors was assessed using Harrell’s concordance index. Results First-line interferon and tyrosine kinase inhibitor were given to 48 (45%) and 41 (38%) patients, respectively, and 28 (26%) and 33 (31%) patients underwent cytoreductive nephrectomy and metastasectomy, respectively. During follow-up (median: 36.3 months), 64 patients died. The median controlling nutritional status score was 2 (range: 0–8). A controlling nutritional status score ≥ 2 was significantly associated with shorter overall survival (P Conclusion The controlling nutritional status score may serve as a prognostic biomarker objectively reflecting the general physical condition of patients with metastatic renal cell carcinoma treated with or without first-line interferon or tyrosine kinase inhibitor in terms of nutritional and immuno-inflammatory status.

The superior longitudinal fascicle/fasciculus (SLF) is a major white matter tract connecting the frontal and parietal cortices in humans. Although the SLF has often been analyzed as a single entity, several studies have reported that the SLF is segregated into three distinct branches (SLF I, II, and III). They have also reported the right lateralization of the SLF III volume and discussed its relationship with lateralized cortical functions in the fronto-parietal network. However, to date, the homogeneity or heterogeneity of the age dependency and lateralization properties of SLF branches have not been fully clarified. Through this study, we aimed to clarify the age dependency and lateralization of SLF I-III by analyzing diffusion-weighted MRI (dMRI) and quantitative R1 (qR1) map datasets collected from a wide range of age groups, mostly comprising right-handed children, adolescents, adults, and seniors (6 to 81 years old). The age dependency in dMRI measurement (fractional anisotropy, FA) was heterogeneous among the three SLF branches, suggesting that these branches are regulated by distinct developmental and aging processes. Lateralization analysis on SLF branches revealed that the right SLF III was larger than the left SLF III in adults, replicating previous reports. FA measurement also suggested that, in addition to SLF III, SLF II was lateralized to the right hemisphere in adolescents and adults. We further found a left lateralization of SLF I in qR1 data, a microstructural measurement sensitive to myelin levels, in adults. These findings suggest that the SLF sub-bundles are distinct entities in terms of age dependency and lateralization.

Background Social determinants of health (SDHs) are social factors that affect human health; loneliness and social isolation are core SDH factors. There is a possibility that SDHs are related to passive decisionmaking. However, few studies have evaluated SDHs, especially social isolation and loneliness, among lung cancer patients. This study aims to investigate the effects of social isolation and loneliness on the diagnosis and treatment of Japanese lung cancer patients. Methods This is a prospective cohort study that was conducted in a tertiary referral hospital in Japan (University Hospital Medical Information Network registration: UMIN000031810). The enrollment period was between April 2018 and March 2020. Patients with clinical and/or pathological diagnosis of lung cancer were enrolled in this study. Exposures were social isolation and loneliness, and main outcomes were diagnosis methods and whether the initial treatment involved active therapy or best supportive care (BSC). The confounding factors were defined as sex, age, smoking status, respiratory symptoms, weight loss, presentation with any symptoms, Eastern Cooperative Oncology Group (ECOG) performance status, tumor nodes metastasis (TNM) classification, driver gene mutations [i.e., epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK)], and programmed death-ligand 1 (PD-L1) tumor proportion score. Results The study enrolled 264 patients who were divided into quartiles according to their loneliness scores and into two groups according to the social isolation level. Univariate analysis, complete case analysis, and multivariate analysis with multiple imputation failed to detect significant differences in diagnostic method or initial treatment strategy according to loneliness or social isolation level. Conclusions Physicians may not need to consider a patient's loneliness and/or social isolation when diagnosing lung cancer and selecting treatment under universal health insurance coverage. Further studies are needed to understand the influences of loneliness and social isolation on the prognosis of lung cancer patients.

Head and neck cancers, especially in hypopharynx and oropharynx, are often detected at advanced stage with poor prognosis. Narrow band imaging enables detection of superficial cancers and transoral surgery is performed with curative intent. However, pathological evaluation and real‐world safety and clinical outcomes have not been clearly understood. The aim of this nationwide multicenter study was to investigate the safety and efficacy of transoral surgery for superficial head and neck cancer. We collected the patients with superficial head and neck squamous cell carcinoma who were treated by transoral surgery from 27 hospitals in Japan. Central pathology review was undertaken on all of the resected specimens. The primary objective was effectiveness of transoral surgery, and the secondary objective was safety including incidence and severity of adverse events. Among the 568 patients, a total of 662 lesions were primarily treated by 575 sessions of transoral surgery. The median tumor diameter was 12 mm (range 1–75) endoscopically. Among the lesions, 57.4% were diagnosed as squamous cell carcinoma in situ. The median procedure time was 48 minutes (range 2–357). Adverse events occurred in 12.7%. Life‐threatening complications occurred in 0.5%, but there were no treatment‐related deaths. During a median follow‐up period of 46.1 months (range 1–113), the 3‐year overall survival rate, relapse‐free survival rate, cause‐specific survival rate, and larynx‐preservation survival rate were 88.1%, 84.4%, 99.6%, and 87.5%, respectively. Transoral surgery for superficial head and neck cancer offers effective minimally invasive treatment. Clinical trials registry number: UMIN000008276., This is the first report on nationwide survival data and pathological criteria of superficial head and neck cancer. Transoral surgery for superficial head and neck cancer was safe and offered highly curative minimally invasive treatment preserving organs and their function. Subepithelial invasion was clinically useful predictor of recurrence after transoral surgery.

Barre-Lieou syndrome (BLS) is a manifestation of various autonomic and secondary symptoms including muscle stiffness, tinnitus, dizziness, and pain in various body parts. Although considered to be caused by hyperactivation of the autonomic nervous system due to trauma, there is currently no firmly established etiology or evidence on the treatment and clinical features of BLS. We retrospectively examined the clinical features of BLS and evaluated the efficacy of trazodone (TZD) for its treatment. We conducted a retrospective analysis of the data of 20 consecutive cases with suspected BLS who were treated in our hospital between 2016 and 2019. BLS symptoms were rated on a 10-point scale, and two groups were defined, that is, a mild-BLS group (BLS scores, 1-5) and a severe-BLS group (BLS scores, 6-10). Univariate analysis of patient factors was performed. The BLS score was 6.0 ± 1.7, and the maximum TZD dose was 80 ± 34 mg/day; nine patients (45%) were TZD free, and no TZD side effects were observed, while all patients had a good clinical outcome. There were significant differences between the mild-BLS and severe-BLS groups in the period from injury to diagnosis (p = 0.015), chest/back pain (p < 0.001), constipation (p = 0.001), and maximum TZD dose (p = 0.008). BLS involves posttraumatic autonomic symptoms accompanied by depression and insomnia. The sympathetic hypersensitivity theory could explain its etiology. TZD could effectively and safely treat BLS, and early diagnosis and treatment can contribute toward good clinical outcomes. Enhanced recognition and understanding of this disease are warranted.

A 42-year-old man with a history of surgery for tongue cancer was referred to our hospital due to an abnormal chest shadow. High-resolution computed tomography showed lower lobe reticulation. A physical examination revealed nail dystrophy, oral leukoplakia, and reticulated hypopigmentation. Lung biopsy revealed subpleural and perilobular fibrosis, suggestive of usual interstitial pneumonia. However, multiple pathological findings, including homogenous fibrosis and cell infiltration in the centrilobular region, which were compatible with nonspecific interstitial pneumonia, and bronchiolitis were also seen. Genetic testing showed a hemizygous missense mutation in the DKC1 gene, and the patient was diagnosed with dyskeratosis congenita. Although anti-fibrotic therapy was initiated, the patient's respiratory function has continued to decrease.

A 40-year-old, male, Japanese patient presented with the complaint of painless, right testicular swelling. Tumor markers for testicular cancer were normal. He underwent radical orchiectomy with the clinical diagnosis of stage I seminoma. Pathological examination revealed seminoma and coexisting neuroendocrine tumor (NET). Germ cell neoplasia in situ (GCNIS) was present in the vicinity of seminoma, but there was no continuity between NET and seminoma. Tumor cells of both lesions displayed amplification of 12p and isochromosome 12p on fluorescence in situ hybridization, suggesting that both tumors originated from GCNIS. The present report is the first to describe a case of primary testicular NET coexisting with seminoma in an ipsilateral testis.

Background In hepatectomy, the preservation of portal perfusion and venous drainage in the remnant liver is important for securing postoperative hepatic function. Right hepatectomy is generally indicated when a hepatic tumor involves the right hepatic vein (RHV). However, if a sizable inferior RHV (IRHV) exists, hepatectomy with preservation of the IRHV territory may be another option. In this case, we verified the clinical feasibility of anatomical bisegmentectomy 7 and 8 with RHV ligation, averting the right hepatic parenchyma from venous congestion, utilizing the presence of the IRHV. Case presentation A 70-year-old man was presented with a large hepatic tumor infiltrating the RHV on computed tomography during a medical checkup. The patient was diagnosed with hepatocellular carcinoma (HCC), T2N0M0, stage III. Right hepatectomy was first considered, but multi-detector computed tomography (MDCT) also revealed a large IRHV draining almost all of segments 5 and 6, suggesting that IRHV-preserving liver resection may be another option. The calculated future remnant liver volumes were 382 mL (26.1% of the total volume) after right hepatectomy and 755 mL (51.7% of the total volume) after anatomical bisegmentectomy 7 and 8; therefore, we scheduled IRHV-preserving anatomical bisegmentectomy 7 and 8 considering the prevention of postoperative liver failure and increased chance of performing repeat resections in cases of recurrence. Preoperative three-dimensional simulation using MDCT clearly revealed the portal perfusion area and venous drainage territories by the RHV and IRHV. There was an issue with invisibility of the anatomical resection line of segments 7 and 8, which was completely dissolved by intraoperative ultrasonography using Sonazoid and the portal dye injection technique with counter staining. The postoperative course in the patient was uneventful, without recurrence of HCC, for 30 months after hepatectomy. Conclusions IRHV-preserving anatomical bisegmentectomy 7 and 8 is a safe and feasible procedure utilizing the three-dimensional simulation of the portal perfusion area and venous drainage territories and the portal dye injection technique.

Background Extrahepatic recurrence and early intrahepatic recurrence of hepatocellular carcinoma after hepatic resection are indicative of poor prognoses. We aimed to develop nomograms to predict extrahepatic recurrence and early intrahepatic recurrence after hepatic resection. Methods The participants of this study were 1,206 patients who underwent initial and curative hepatic resection for hepatocellular carcinoma. Multivariate logistic regression analyses using the Akaike information criterion were used to construct nomograms to predict extrahepatic recurrence and early intrahepatic recurrence (within 1 year of surgery) at the first recurrence sites after hepatic resection. Performance of each nomogram was evaluated by calibration plots with bootstrapping. Results Extrahepatic recurrence was identified in 95 patients (7.9%) and early intrahepatic recurrence in 296 patients (24.5%). Three predictive factors, α-fetoprotein >200 ng/mL, tumor size (3–5 cm or >5 cm vs ≤3 cm), and image-diagnosed venous invasion by computed tomography, were adopted in the final model of the extrahepatic recurrence nomogram with a concordance index of 0.75. Tumor size and 2 additional predictors (ie, multiple tumors and image-diagnosed portal invasion) were adopted in the final model of the early intrahepatic recurrence nomogram with a concordance index of 0.67. The calibration plots showed good agreement between the nomogram predictions of extrahepatic recurrence and early intrahepatic recurrence and the actual observations of extrahepatic recurrence and early intrahepatic recurrence, respectively. Conclusion We have developed reliable nomograms to predict extrahepatic recurrence and early intrahepatic recurrence of hepatocellular carcinoma after hepatic resection. These are useful for the diagnostic prediction of extrahepatic recurrence and early intrahepatic recurrence and could guide the surgeon’s selection of treatment strategies for hepatocellular carcinoma patients.

Indocyanine green (ICG) is a fluorescent dye that selectively accumulates in primary hepatocellular carcinoma (HCC) as well as in extrahepatic metastases of HCC. Reported here is a case of metachronous lymph node (LN) metastases from HCC that were resected using ICG fluorescence navigation. A man in his 70s was referred to this department for suspected LN metastasis from HCC. Computed tomography revealed an enlarged suprapancreatic LN. After a laparotomy, an ICG fluorescence imaging system intraoperatively revealed strong fluorescence of this LN, which was then easily resected. An examination after the removal of the LN revealed fluorescence from the adjacent lymphatic tissue as well, so an additional resection was performed. Pathologically, both LNs were confirmed to be metastases from HCC. In this case, some lymphatic tissue metastases from HCC could not be identified prior to surgery, but intraoperative use of ICG fluorescence navigation facilitated their complete removal.

BACKGROUND: The controlling nutritional status (CONUT) score is an objective indicator of general condition from the aspect of nutritional status, calculated from serum albumin, total cholesterol, and total lymphocyte count. The CONUT score is also considered to reflect the degree of tumor-derived chronic inflammation and the host immune status in patients with advanced cancer. OBJECTIVE: To examine the prognostic role of the CONUT score in patients with advanced urothelial carcinoma (aUC) treated with first-line platinum-based chemotherapy. METHODS: Associations of the CONUT score with clinical parameters and overall survival (OS) were investigated retrospectively in 147 patients with aUC receiving first-line platinum-based chemotherapy at a single cancer center from February 2003 to April 2019. RESULTS: The median (range) CONUT score was 1 (0–7). A higher CONUT score was associated with lower hemoglobin (P

The most common treatment for advanced gastric cancer (AGC) is systemic chemotherapy. The standard treatment for advanced gastric cancer differs worldwide. In Japan, two phase III clinical trials demonstrated the non-inferiority of S-1 compared with 5-fluorouracil (5-FU) and superiority of cisplatin plus S-1 (CS), compared with S-1, with respect to overall survival (SPIRITS trial). Oxaliplatin (L-OHP) has a favorable toxicity profile compared with cisplatin; hence, a phase III clinical trial (G-SOX trial) demonstrated the progression-free survival (PFS) and overall survival in CS was 5.4 and 13.1 months and those in SOX was 5.5 and 14.1 months, respectively. Serious adverse events were more frequently seen in CS than in SOX. So, SOX is as effective as CS for advanced gastric cancer with favorable safety profile. After the publication of this G-SOX trial, the combination of oral or intravenous 5-FU and various doses of L-OHP have been reported. And FOLFOX6 regimen (FOLFOX: a combination of 1-LV and FU with L-OHP) was approved for the treatment of AGC in Japan in 2017. FOLFOX was promising for patients with severe peritoneal metastasis from AGC, because the FOLFOX regimen does not require hydration and does not include oral agents. This review summarizes the efficacy and safety of doublet combinations of platinum and fluoropyrimidines using L-OHP for advanced gastric cancer.

Graphical abstract, Highlights • Primary malignant cardiac tumors are very rare. • This is the first case report of intimal sarcoma of left atrial origin. • Echocardiographic diagnosis of malignant cardiac tumor is critical but challenging. • The authors outline the differentiation of primary malignant cardiac tumors.

There are two types of pyloric gland-like metaplasia in the corpus of stomach: pyloric and pseudopyloric metaplasias. They show the same morphology as the original pyloric glands in H&E staining. Pseudopyloric metaplasia is positive for pepsinogen (PG) I immunohistochemically, whereas pyloric metaplasia is negative. Recently, spasmolytic polypeptide-expressing metaplasia (SPEM) is proposed for pyloric gland-like metaplasia mainly in animal experiments. SPEM expresses trefoil factor family 2 (TFF2) and is often considered synonymous with pseudopyloric metaplasia. We reviewed consecutive 22 Japanese patients with autoimmune gastritis (AIG) to investigate TFF2 expression in pyloric and pseudopyloric metaplasias by counting all pyloric gland-like glands in biopsy specimens taken from greater curvature of the middle corpus according to the Updated Sydney System. Pyloric metaplasia was seen in all the 22 cases, and pseudopyloric metaplasia was found in 15 cases. Of 1567 pyloric gland-like glands in all the cases, 1381 (88.1%) glands were pyloric metaplasia glands, and the remaining 186 (11.9%) glands were pseudopyloric metaplasia glands. TFF2 expression was observed in pyloric or pseudopyloric metaplasia glands in 20 cases. TFF2 expression was recognized in 409 of 1381 (26.9%) pyloric metaplasia glands and 27 of 186 (14.5%) pseudopyloric metaplasia glands (P

BACKGROUND Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a biopsy technique widely used to diagnose pancreatic tumors because of its high sensitivity and specificity. Although needle-tract seeding caused by EUS-FNA has been recently reported, dissemination of pancreatic cancer cells is generally considered to be a rare complication that does not affect patient prognosis. However, the frequency of dissemination and needle-tract seeding appears to have been underestimated. We present a case of peritoneal dissemination of pancreatic cancer due to preoperative EUS-FNA. CASE SUMMARY An 81-year-old man was referred to the Department of Surgery of our hospital in Japan owing to the detection of a pancreatic mass on computed tomography during medical screening. Trans-gastric EUS-FNA revealed that the mass was an adenocarcinoma; hence laparoscopic distal pancreatectomy with lympha-denectomy was performed. No intraoperative peritoneal dissemination and liver metastasis were visually detected, and pelvic lavage cytology was negative for carcinoma cells. The postoperative surgical specimen was negative for carcinoma cells at the dissected margin and the cut end margin; however, pathological findings revealed adenocarcinoma cells on the peritoneal surface proximal to the needle puncture site, and the cells were suspected to be disseminated via EUS- FNA. Hence, the patient received adjuvant therapy with S-1 (tegafur, gimeracil, and oteracil potassium); however, computed tomography performed 5 mo after surgery revealed liver metastasis and cancerous peritonitis. The patient received palliative therapy and died 8 mo after the operation. CONCLUSION The indications of EUS-FNA should be carefully considered to avoid iatrogenic dissemination, especially for cancers in the pancreatic body or tail.

Aim Ventilator-associated pneumonia (VAP) is the most common intensive care unit (ICU)-acquired infection. The current study aimed to assess the efficacy of mechanical insufflation-exsufflation (MI-E) in preventing VAP in critically ill patients. Materials and methods This retrospective cohort study was conducted at the ICU of Chiba University Hospital between January 2014 and September 2017. The inclusion criteria were patients who required invasive mechanical ventilation ≥48 hours and those who underwent rehabilitation, including chest physical therapy (CPT). In 2015, the study institution started the use of MI-E in patients with impaired cough reflex. From January to December 2014, patients undergoing CPT were classified under the historical control group, and those who received treatment using MI-E from January 2015 to September 2017 were included in the intervention group. The patients received treatment using MI-E via the endotracheal or tracheostomy tube, with insufflation-exsufflation pressure of 15-40 cm H2O. The treatment frequency was one to three sessions daily, and a physical therapist who is experienced in using MI-E facilitated the treatment. Results From January 2015 to September 2017, 11 patients received treatment using MI-E. Of the 169 patients screened in 2014, 19 underwent CPT. The incidence of VAP was significantly different between the CPT and MI-E groups (84.2% [16/19] vs 26.4% [3/11], p = 0.011). After adjusting for covariates, a multivariate logistic regression analysis was performed, and results showed that the covariates were not associated with the incidence of VAP. Conclusion This retrospective cohort study suggests that the use of MI-E in critically ill patients is independently associated with a reduced incidence of VAP. Clinical significance Assessing the efficacy of MI-E to prevent VAP. How to cite this article Kuroiwa R, Tateishi Y, Oshima T, Inagaki T, Furukawa S, Takemura R, et al. Mechanical Insufflation-exsufflation for the Prevention of Ventilator-associated Pneumonia in Intensive Care Units: A Retrospective Cohort Study. Indian J Crit Care Med 2021;25(1):62-66.

To elucidate the incidence, causes, and risk factors associated with readmission due to transplant-related complications, we studied 213 consecutive patients who were discharged without progression of primary disease after their first allogeneic hematopoietic cell transplantation at our center between 2013 and 2016. The median patient age was 50 years (range, 18-71 years). Eighty-three patients had AML or MDS, 66 had lymphoma, 28 had ALL, 23 had ATL, and 13 had other diseases. The median duration of hospitalization for transplantation was 56 days (range 27-325 days). The cumulative incidences of readmission due to transplant-related complications were 8% at 30 days, 16% at 100 days, and 25% at 1 year after discharge. The most frequent cause of readmission was infection, followed by graft-versus-host disease throughout the first year. In multivariate analysis, steroid use at discharge was the only risk factor associated with readmission within 30 days, and steroid use at discharge, absolute lymphocyte count < 500/µl at discharge, and documented bacterial infection during admission were risk factors associated with readmission within 1 year. Our results indicated that factors during hospitalization or discharge, but not at transplantation, were associated with readmission. Patients with these risk factors should be monitored carefully after discharge.

Introduction Routine preoperative testing for low-risk surgeries without a clinical indication should be avoided; however, such tests are still frequently performed in Japan. This study was performed to assess the impact of routine preoperative tests in low-risk surgery in a Japanese medical setting. Methods We performed a retrospective chart review to examine the utility of routine tests with respect to anesthetic management and postoperative complications in all patients aged ≥ 18 years whom ophthalmologists consulted with anesthesiologists before ophthalmologic surgery under general anesthesia. Results During the 10-year study period, 1,234 anesthetic consultations and 1,211 routine preoperative tests (laboratory tests, chest X-rays, and electrocardiograms) were performed in Toyama University Hospital. In total, 59 patients (4.8% of the study population) canceled surgery after a battery of preoperative evaluation. Among them, 10 patients had incidental abnormalities that necessitated additional tests, and only three patients (0.2%) canceled surgery. In-hospital postoperative complications developed in nine patients (0.7%) whose routine test results made it difficult to predict development of these adverse events. No severe life-threatening events were noted in this survey. Conclusions Routine tests prior to eye surgery for adults were of low value for perioperative management and prediction of development of in-hospital complications in this Japanese medical setting. Anesthesiologists and ophthalmologists should selectively order preoperative tests based on the medical interview and physical examination.

研究グループは、肝細胞癌の腫瘍分化度による予後不良リスクは腫瘍サイズとともに増大することを明らかにしました。近年国内でも増加している生活習慣病などが原因となって発症する肝細胞癌ですが、肝細胞癌における腫瘍分化度と予後との関連性は一定の見解が得られておらず、欧州肝臓学会のガイドラインでも「結論に至っていない」と示されています。今回1,107例の肝細胞癌肝切除症例を対象に検討したところ、低分化型は術後予後不良因子であり、腫瘍サイズ5cmまでは予後不良リスクが急激に上昇することが分かりました。腫瘍サイズを, Introduction: The present study aimed to evaluate the effect of poor differentiation and tumor size on survival outcome after hepatic resection of hepatocellular carcinoma (HCC). / Methods: A total of 1,107 patients who underwent initial and curative hepatic resection for HCC without macroscopic vascular invasion participated in the study. Using the multivariable Cox proportional hazards regression model, we evaluated changes in hazard ratios (HRs) for the association between tumor differentiation and survival based on tumor size....

Idiopathic pulmonary fibrosis (IPF), an incurable lung disease of unknown cause, often presents with losses of skeletal muscle mass. IPF requires comprehensive care, but it has not been investigated which skeletal muscle mass index reflects holistic management factors: pulmonary function, patient-reported outcomes (PROs), and physical performance. We compared three representative indices of skeletal muscle mass with holistic management factors in IPF patients. Twenty-seven mild to severe IPF patients (21 male) with the mean age of 76.1 ± 5.9 years were enrolled. The three indices were appendicular skeletal muscle mass index (ASMI), cross-sectional area of pectoralis major (PMCSA), and cross-sectional area of erector spinae muscles (ESMCSA). ASMI is considered as a gold standard for sarcopenia assessment, while PMCSA and ESMCSA are frequently used in IPF. As PROs, we assessed breathlessness with the modified Medical Research Council dyspnea scale (mMRC), symptoms with the chronic obstructive pulmonary disease assessment test (CAT), and health-related quality of life with St. George's Respiratory Questionnaire (SGRQ). For physical performance, peripheral muscle strength and 6-min walk distance (6MWD) were investigated. In this cross-sectional study, ASMI showed the greatest number of significantly correlated indices, such as pulmonary function, peripheral muscle strength, 6MWD, mMRC, and SGRQ. PMCSA showed the next greatest number of correlations, with peripheral muscle strength, 6MWD, and mMRC, whereas ESMCSA showed no significant correlations with any index. Thus, ASMI correlated with both PROs and physical performance, and PMCSA correlated mainly with physical performance. In conclusion, assessing ASMI is helpful for the comprehensive care of patients with IPF.

Mechanical testing and gait measurement for ankle-foot orthosis (AFO) are crucial for determining the AFO stiffness magnitude in an individual. However, information on the effect of the stiffness magnitude on the muscle force during gait is limited. This study aimed to investigate the relationship between the AFO stiffness and ankle muscle force during gait. The AFO stiffness was mechanically tested using a six-axis robot arm. The stiffness magnitude was adjusted using different spring constants. Five stiffness conditions were set for each plantarflexion resistive (PFR) and dorsiflexion resistive (DFR) function. The effect of the PFR and DFR on the ankle muscle force during gait were determined using musculoskeletal and AFO models. Tibialis anterior (TA) and triceps surae (TS) muscle forces were calculated through gait simulation. The angle-moment relationships display hysteresis loops for each condition. One of the PFR and DFR conditions differed significantly from the others (for all, p < 0.05). In order of lower stiffness, the each PFR contribution ratio to the peak TA muscle force normalized in the no-stiffness condition was 8.4%, 10.8%, 11.3%, 13.5%, and 15.3%; while the each DFR contribution ratio to the peak TS muscle force was 16.2%, 20.9%, 25.3%, 29.8%, and 30.5%, respectively. Through mechanical testing as well as gait simulation, it was demonstrated that the magnitude of the AFO stiffness decreased the required ankle muscle force during gait. This study can contribute to more effective gait rehabilitation using AFO as well as AFO fabrication with customized stiffness for individual gait function.