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Background: Obstructive sleep apnea (OSA) occurs more commonly in asthma patients than in the general population because these conditions share some comorbidities. In Japan, the prevalence of OSA in the general population is reported to be approximately 20%; however, few reports have described the prevalence of OSA in asthma patients. Furthermore, the characteristics of Japanese patients with OSA and asthma are not clear., Methods: Adult asthma patients were recruited from the outpatient departments of our institution between August 31, 2017, and March 31, 2019. In all included patients, the presence and severity of OSA were evaluated by the Epworth Sleepiness Scale (ESS) and a home sleep test (HST) using portable polysomnography (PSG). The rate of coexisting OSA in asthma patients and the characteristics of those patients according to the severity of OSA were investigated., Results: Fifty-three patients were included. OSA was detected in 36 (67.9%) patients (mild, n = 15; moderate, n = 14; and severe, n = 7). Patients with OSA had significantly higher body mass index, Brinkman index, apnea-hypopnea index (AHI), and 3% oxygen desaturation index (ODI) values in comparison to those without OSA, while the percentage of the predicted value of forced vital capacity (%FVC) and lowest SpO 2 levels were significantly lower. As the severity of OSA increased, age, brain natriuretic peptide level, AHI, and 3%ODI increased, and in contrast, FVC, %FVC, forced expiratory volume in one second (FEV 1 ), percentage of the predicted value of FEV 1 (%FEV 1 ), Epworth Sleepiness Scale (ESS), 3%ODI, and lowest SpO 2 levels decreased. In particular, the fact that the ESS value was inversely correlated with the severity of OSA in our patients was different from the general characteristics of OSA. Moreover, the AHI value was negatively correlated with FVC, %FVC, FEV 1 , and %FEV 1 . BMI was the only independent factor for the presence of OSA, and for asthma severity (FEV1, % of predicted), there was a weak correlation with smoking history., Conclusions: This is the first report to investigate the prevalence of OSA in Japanese asthma patients, using an HST. This study suggests that an HST should be performed in addition to the sleep interview for asthma patients with refractory disease, a low pulmonary function, advanced age, and high BMI because the more severe the OSA, the lower the ESS value may be., (© 2024. The Author(s).)

A 75-year-old woman on hemodialysis for end-stage renal failure due to polycystic kidney disease developed dark spots on her limbs. She had been treated for extended spectrum beta-lactamase-producing Escherichia coli bacteremia by a rectovaginal fistula and was on long-term oral minocycline (cumulative dose 45 g). Physical examination revealed dark patches on her forearms and lower legs but no trunk hyperpigmentation or visual impairment. Blood tests were normal. Skin biopsy confirmed minocycline-induced hyperpigmentation. Minocycline-induced pigmentation is categorized into types I-IV, each with unique clinical and histopathological features. Types I and II are reversible upon discontinuing minocycline, whereas types III and IV are permanent. The patient was diagnosed with type II pigmentation, generally occurring with a cumulative dose exceeding 70-100 g; however, her lower dose (45 g) led to pigmentation, possibly influenced by her vitamin D deficiency. Clinicians should evaluate the antimicrobial indication and treatment period, considering not only the benefits but also the side effects and antimicrobial resistance. If minocycline is used, attention should be paid to minocycline-induced hyperpigmentation, and this possibility should be communicated to patients to enable early detection., Competing Interests: None., (© 2023 The Authors.)

Background: This study aims to evaluate the accuracy of the axis connecting both anterior superior iliac spines (ASIS axis) as the absolute pelvic axis. No study has ever verified the accuracy of ASIS axis particularly on the AP pelvic radiograph, which cannot be specified on it., Methods: Sixty patients who underwent total knee arthroplasty and fifty patients with femoral neck fracture were recruited as subjects without hip deformities and their CT scan data were collected. We defined the line through both center of femoral heads as absolute reference axis of pelvis three-dimensionally. On the coronal plane, the errors between the femoral head axis and the axes through six pelvic landmarks in total, including ASIS were analyzed. On the axial plane, the errors of the lines through four landmarks were analyzed in the same way. Finally, on the coronal images, the mediolateral diameter of the obturator foramen and the mediolateral distance between the midline of the sacrum and the pelvic cavity were measured to evaluate bilateral symmetry of the pelvis., Results: The errors tended to be smaller as the axes were closer to the femoral head axis (axes connecting bilateral superior aspects of the acetabulum and the teardrops) and the ASIS axis errors were moderate. The obturator foramen based on the ASIS axis was more asymmetrical than the femoral head axis., Conclusion: Adjusting the pelvic tilt and rotation, surgeons should not always rely on the ASIS and refer to appropriate, close to the hip joint references in each case., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2022. Published by Elsevier B.V.)

The potential use of quick SOFA (qSOFA) score and inflammatory biomarkers as bacteremia predictors is unelucidated. Herein the aim of this study was to evaluate the diagnostic accuracy of the qSOFA score and biomarkers for predicting community-onset bacteremia. We enrolled adult outpatients with blood culture samples drawn between 2018 and 2020. Contamination, intensive care unit admission, and hemodialysis were excluded. We performed a case-control study, and analyzed 115 patients (58 with bacteremia and 57 without bacteremia). The positive likelihood ratio (LR) for bacteremia was 2.46 (95% confidence interval [CI] 0.76-9.05) for a qSOFA score ≥ 2, and 4.07 (95% CI 1.92-9.58) for tachypnea (≥ 22/min). The highest performing biomarkers were procalcitonin (area under the curve [AUC] 0.80; 95% CI 0.72-0.88), followed by presepsin (AUC 0.69; 95% CI 0.60-0.79), and C-reactive protein (AUC 0.60; 95% CI 0.49-0.70). The estimated optimal cut-off value of procalcitonin was 0.377 ng/mL, with a sensitivity of 74.1%, a specificity of 73.7%, and a positive LR of 2.82. Presepsin was 407 pg/mL, with a sensitivity of 60.3%, a specificity of 75.4%, and a positive LR of 2.46. Procalcitonin was found to be a modestly useful biomarker for predicting non-severe community-onset bacteremia. Tachypnea (≥ 22/min) itself, rather than the qSOFA score, can be a diagnostic predictor. These predictors may aid decision-making regarding the collection of blood culture samples in the emergency department and outpatient clinics., (© 2022. The Author(s).)

Background: Unlike Escherichia coli bacteremia, which is common, E. coli endocarditis is uncommon, particularly in patients with native valve, leading to its delayed diagnosis., Case Presentation: We present a case of infective endocarditis caused by E. coli in a 78-year-old Japanese man with type 2 diabetes, involving persistent bacteremia and vegetation on the mitral valve (measuring 18 × 4.2 mm in diameter). He presented with recurrent fever after antimicrobial treatment for pyelonephritis. He received antibiotic therapy for 6 weeks and required surgical removal of a calcified amorphous tumor and vegetation with mitral valvuloplasty 7 days after admission. Despite an episode of multiple cerebral infarctions, he recovered fully from the infection., Conclusions: Follow-up blood cultures should be performed for Gram-negative bacilli bacteremia among patients with unknown focus and an atypical clinical course after treatment. Early diagnosis and aggressive surgical intervention are paramount to achieving good clinical outcomes., (© 2022. The Author(s).)

Background: The key virulence factors responsible for hypervirulent Klebsiella pneumoniae (hvKp) infection remains elusive., Methods: We analyzed K. pneumoniae isolates collected between 2017 and 2019 and defined hvKp as a pyogenic infection. Classical K. pneumoniae (cKp) involved a non-invasive infection or uncomplicated bacteremia. Isolates belonging to the K. pneumoniae species complex were excluded., Results: We analyzed 112 isolates, including 19 hvKp, 67 cKp, and 26 colonizers, using whole-genome sequencing. Population genomics revealed that the K1-sequence type (ST) 82 (O1v1) clade was distinct from that of the K1-ST23 (O1v2) clone. The virulence gene profiles also differed between K1-ST82 (aerobactin and rmpA) and K1-ST23 (aerobactin, yersiniabactin, salmochelin, colibactin, and rmpA/rmpA2). The K2 genotype was more diverse than that of K1. A neighboring subclade of K1-ST23 (comprising ST29, ST412, ST36, and ST268) showed multidrug resistance and hypervirulence potentials. Logistic-regression analysis revealed that diabetes mellitus was associated with K. pneumoniae infection (odds ratio [OR]: 4.11; 95% confidence interval [CI]: 1.14-14.8). No significant association was found between hvKp diagnosis and clinical characteristics, such as diabetes mellitus or community acquisition. However, the K1 genotype (OR: 9.02; 95% CI: 2.49-32.7; positive-likelihood ratio [LR]: 4.08), rmpA (OR: 8.26; 95% CI: 1.77-38.5; positive LR: 5.83), and aerobactin (OR: 4.59; 95% CI: 1.22-17.2; positive LR: 3.49) were substantial diagnostic predictors of hvKp., Conclusions: The K1 genotype, rmpA, and aerobactin are prominent predictors of hvKp, suggesting that further pyogenic (metastatic) infection should be examined clinically. These findings may shed light on key hvKp virulence factors., (© 2022. The Author(s).)

Laparoscopic gastrostomy tube placement has been increasingly adopted by pediatric surgeons. We herein report our experience with the performance of a laparoscopic-assisted Stamm-operation inside the minimal trocar site without the extension of the trocar site incision or mini-laparotomy. We present some technical modifications that facilitate suturing inside the minimal trocar site., Methods: A retrospective chart review was conducted of cases involving patients who underwent laparoscopic-assisted gastrostomy, using a simple extracorporeal method inside the trocar site from April 1998 to March 2018., Results: One hundred five gastrostomy tubes were placed in a laparoscopic-assisted operation. All but two of the cases involved patients with neurological impairment. The mean age was 12.5 years; 28 cases were > 16 years of age. Seventy-five cases underwent gastrostomy during laparoscopic fundoplication. All gastrostomy procedures were completed without intraoperative difficulties; however, 8 cases, which involved a thick abdominal wall, required extension of the trocar site. No cases required conversion to open gastrostomy. No major complications were observed. Two patients developed continuous peristomal cellulitis after surgery, due to the mismatch of the site position and an unsuitable button device size., Conclusion: We demonstrated that laparoscopic gastrostomy with fully extracorporeal suturing within the trocar site is feasible and beneficial, especially for the most neurologically impaired pediatric cases. Technical modification, changing the order of the process, and suturing technique in the minimal space, made it easier to perform the procedures inside the minimal trocar hole.

We report a rare case of adenocarcinoma arising in a gastric partial diverticulum in the upper portion of the stomach. The lesion had been followed up for approximately 14 years as a gastric submucosal tumor. However, a recent regular check-up revealed mucous material with some neoplastic tissue discharged from the top of the lesion. A surgically resected specimen showed a well-demarcated submucosal lesion identical to a pseudo-diverticulum carrying a distinctive intramucosal minimally invasive adenocarcinoma in part, with surrounding non-neoplastic but hyperplastic mucosal components. Intestinal phenotype, along with gastric foveolar, pyloric gland-type phenotypes, and neoplastic cells with neuroendocrine differentiation, were also identified in the adenocarcinoma. Chronic and persistent irritation within the diverticulum was postulated to be implicated in the carcinogenesis of the lesion, which carried no definite Helicobacter pylori microorganisms. We believe it is crucial not to overlook carcinoma in a diverticulum presenting as a long-standing submucosal tumor.

Endoscopic submucosal dissection (ESD) is accepted as minimally invasive therapy for early stage digestive tract tumors. It has allowed the achievement of histologically curative en-bloc resection of early stage digestive tract tumors regardless of size, including the resection of previously non-resectable tumors. Although numerous electrosurgical knives have been developed for ESD, technical difficulties and high complication rates (bleeding and perforation) have limited their use worldwide. Furthermore, conventional ESD usually needs several devices for each session. We developed the Clutch Cutter® (CC), which can grasp and incise the targeted tissue using electrosurgical current, to resolve such ESD-related problems. The ESD procedure using the CC is as follows: after marking using the CC and the injection of a solution into the submucosa, the lesion is separated from the surrounding normal mucosa by complete incision around the lesion using the CC. A piece of submucosal tissue is grasped and cut with the CC using electrosurgical current to achieve submucosal exfoliation. Intraoperative bleeding is also treated by the CC. Reported clinical studies showed that ESD using the CC is a safe, simple, easy-to-learn, technically efficient (en-bloc resection rate 100%), and a single-device method for the dissection of early stage digestive tract tumors. This new approach is promising to become the worldwide method of choice for early stage digestive tract tumors because it is technically simple and safe to perform., (Copyright © 2012 S. Karger AG, Basel.)

Background: The outcome of thoracoscopic bullectomy for primary spontaneous pneumothorax (PSP) is not satisfactory. To reduce postoperative pneumothorax recurrence after thoracoscopic bullectomy, an effective and easy surgical method is required. We tried a new method using an absorbable mesh that covered the whole apical visceral pleura., Methods: A total of 157 sides of 143 patients who underwent stapled bullectomy under thoracoscopy for PSP were reviewed retrospectively. In the apical covering group (group A), a 15 x 15-cm(2) absorbable mesh sheet was placed on the apical visceral pleura with fibrin glue. Patients in group B underwent bullectomy alone. Cumulative postoperative recurrence was compared between the groups. Recurrent cases in group A were examined clinicopathologically., Results: Group A had 111 cases and group B had 46. There was no operative mortality. Postoperative recurrence occurred in 15 of 157 cases (9.6%): 4 in group A and 11 in group B. The cumulative postoperative 5-year recurrence rate was 3.6% in group A and 23.9% in group B (log-rank test, p = 0.013). In group A, local adhesion was seen at the apical pleurae, and inflammatory changes with foreign body giant cells were seen at the pleura covered with the mesh., Conclusions: Placement of a wide absorbable mesh with fibrin glue at the apical visceral pleura significantly reduced postoperative recurrence after thoracoscopic bullectomy for PSP. The mesh was thought to act as a foreign body on the pleura and induce local inflammatory adhesion between the apical pleurae after bullectomy. This was an easy and effective symphysial procedure.

Endoscopic submucosal dissection (ESD) with a knife is a technically demanding procedure associated with a high complication rate. The shortcomings of this method are the inability to fix the knife to the target lesion, and compression of the lesion. These can lead to major complications such as perforation and bleeding. To reduce the risk of complications related to ESD, we developed a new grasping type scissors forceps (GSF), which can grasp and incise the targeted tissue using electrosurgical current. Colonoscopy on a 55-year-old woman revealed a 10-mm rectal submucosal nodule. The histological diagnosis of the specimen obtained by biopsy was carcinoid tumor. Endoscopic ultrasonography demonstrated a hypoechoic solid tumor limited to the submucosa without lymph node involvement. It was safely and accurately resected without unexpected incision by ESD using a GSF. No delayed hemorrhage or perforation occurred. Histological examination confirmed the carcinoid tumor was completely excised with negative resection margin.

We report the first successful outcome of a patient undergoing concomitant surgery for a left atrial myxoma and a squamous cell carcinoma of the lung. Preoperative evaluations revealed lung cancer and a left atrial tumor of undetermined origin. An operation to excise both cardiac and pulmonary tumors was performed. The cardiac tumor was first resected with the aid of cardiopulmonary bypass. The histopathological diagnosis was myxoma. Resection of the left upper pulmonary lobe and mediastinal lymph nodes followed. The postoperative course was uneventful, and the patient is well without evidence of recurrence 7 years after the operation.

Background: No consensus exists as to the best endoscopic treatment for Mallory-Weiss syndrome. Endoscopic band ligation is a readily available and easily learned technique. This prospective study evaluated the efficacy and safety of endoscopic band ligation therapy for Mallory-Weiss syndrome., Methods: From August 1998 to June 2005, a clinical trial assessed 37 patients with a diagnosis of Mallory-Weiss syndrome who had active bleeding, exposed vessels, or both. Their lesions were treated using endoscopic band ligation., Results: Endoscopic band ligation was successful in 36 of 37 cases, with a follow-up period ranging from 1 to 24 months. The remaining patient had severe liver failure and disseminated intravascular coagulation. The patient bled again at 12 h and subsequently died. Except for this case, no recurrent bleeding, perforation, or other complications occurred., Conclusions: The study results suggest that endoscopic band ligation is an effective, safe, and easily learned procedure for treating upper gastrointestinal bleeding related to Mallory-Weiss syndrome.