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In recent years, there has been an increasing number of studies on neurological symptoms induced as paraneoplastic neurological syndrome (PNS) or neurological immune-related adverse events (irAEs) in patients treated with immune checkpoint inhibitors (ICIs). Herein, we report a 68-year-old male patient with small-cell lung cancer who developed memory impairment and autonomic nervous system dysfunction after three courses of carboplatin, etoposide, and durvalumab therapy. Brain magnetic resonance imaging revealed hyperintense areas restricted to the bilateral temporal lobes. Moreover, based on the blood test results, the patient was strongly positive for anti-neuronal nuclear antibodies. Hence, he was diagnosed with autoimmune limbic encephalitis (ALE). Corticosteroid pulse therapy was administered. After treatment, the patient exhibited gradual improvement in memory impairment. However, while tapering the prednisolone dose, the patient exhibited relapse of memory disturbance owing to ALE. It is challenging to distinguish PNS from neurological irAEs. However, ICI-induced ALE with positivity for anti-Hu antibodies has an extremely poor prognosis., Competing Interests: None declared., (© 2024 The Author(s). Respirology Case Reports published by John Wiley & Sons Australia, Ltd on behalf of The Asian Pacific Society of Respirology.)

Background: Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare tumors with low malignant potential that usually occur in young girls and women. This study investigated the treatment experiences and outcomes after surgery for pediatric SPNs in our institutions as pediatric case series of solid SPNs are few, and long-term follow-up is also limited., Methods: We retrospectively reviewed the outcomes of nine patients diagnosed with SPNs who underwent surgery in our three hospitals (The Jikei University Hospital, The Jikei University Kashiwa Hospital, and Kawaguchi Municipal Medical Center) between 2001 and 2023., Results: All nine patients who underwent surgery were girls. Their ages ranged from 8 to 15 years (median: 10 years). The location of the tumor was at the pancreatic head, body, and tail in five, one, and three patients, respectively. Enucleation, pancreaticoduodenectomy, and laparoscopic distal pancreatectomy (LDP) were performed in four, two, and three patients, respectively. Regarding postoperative complications, a pancreatic fistula was detected in six patients, with three and three patients having grades A and B fistulas, respectively; two patients required percutaneous drainage, and one patient required endoscopic ultrasonography (EUS)-guided transgastric drainage. The follow-up period ranged from six to 261 months (median: 97 months). At the final follow-up, all nine patients were alive without recurrence., Conclusion: SPNs of the pancreas are incidentally diagnosed by diagnostic workups following trauma in children more frequently compared to adults. Additionally, the tumor resection by minimally invasive approaches, such as enucleation, or laparoscopic procedures results in a good prognosis in some cases., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Harada et al.)

Background and Aim: Few studies have evaluated the adenoma detection rate (ADR) of colonoscopy with texture and color enhancement imaging (TXI), a novel image-enhancing technology. This study compares the detection of colorectal polyps using TXI to that using white light imaging (WLI)., Methods: This single-center retrospective study used propensity-matched scoring based on the patients' baseline characteristics (age, sex, indication, bowel preparation, endoscopist, colonoscope type, and withdrawal time) to compare the results of patients who underwent chromoendoscopy using WLI or TXI at the Toyoshima Endoscopy Clinic. The differences in polyp detection rates and the mean number of detected polyps per colonoscopy were determined between the TXI and WLI groups., Results: After propensity score matching, 1970 patients were enrolled into each imaging modality group. The mean patient age was 57.2 ± 12.5 years, and 44.5% of the cohort were men. The ADR was higher in the TXI group than in the WLI group (55.0% vs 49.4%, odds ratio: 1.25). High-risk ADR were more common in the TXI group than in the WLI group (17.6% vs 12.8%; OR: 1.45). The mean number of adenomas per colonoscopy (APC) was higher in the TXI group than in the WLI group (1.187 vs 0.943, OR: 1.12). APC with a flat morphology (1.093 vs 0.848, OR: 1.14) and APC of <6 mm (0.992 vs 0.757, OR: 1.16) were higher in the TXI group than in the WLI group., Conclusion: Compared to WLI, TXI improved the ADR in patients who underwent chromoendoscopy based on actual clinical data., (© 2024 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Introduction: Estimated continuous cardiac output (esCCO) is a novel technology that enables non-invasive and continuous monitoring of cardiac output. We compared the concordance in accuracies among esCCO measurements in the shunt limb and non-shunt limb., Methods: In this single-center prospective observational study, we include Japanese patients who underwent dialysis at our center between April 27, 2021, and February 28, 2023. Clinical accuracy of esCCO was evaluated in the shunted and non-shunted bilateral digits. Agreement between the measurements was analyzed using Lin's congruent correlation and Bland-Altman analysis., Results: For 43 individuals, Lin's concordance correlation coefficient was 0.9887 (95% confidence interval of 0.9886-0.9887) indicating good agreement. The values of esCCO measured in the shunt and non-shunt limbs were compatible. The percentage errors for the 43 patients with arterio-venous fistula (AVF) or arterio-venous graft (AVG), 32 with AVF, and 11 with AVG were 9.3%, 9.3%, and 8.9%, respectively., Conclusion: esCCO could be used in shunt as well as non-shunt limbs during dialysis, allowing continuous and non-invasive hemodynamic monitoring., (© 2024 The Author(s). Therapeutic Apheresis and Dialysis published by John Wiley & Sons Australia, Ltd on behalf of International Society for Apheresis and Japanese Society for Apheresis.)

Objective: The relationship between the healing time of pressure ulcers (PUs) and wound cleaning frequency among older people in homecare settings was investigated., Method: This single-centre, prospective cohort study was conducted from April 2018 to March 2019. Patients who used home-visit nursing services, had National Pressure Ulcer Advisory Panel classification stage 2 PUs, and had their wounds cleaned at least twice a week were enrolled in the study. Wound cleaning was performed using tap water and a weakly acidic cleanser. Participants were divided into two groups, determined by the frequency of wound cleaning (twice weekly versus ≥3 times weekly). Duration of PU healing and the increase in care insurance premiums were compared in both groups., Results: A total of 12 patients were included in the study. The mean healing period of PUs cleaned ≥3 times per week (65.3±24.8 days) was significantly shorter than that of PUs cleaned twice a week (102.6±19.2 days; p<0.05). Furthermore, the increase in care insurance premiums for PUs cleaned ≥3 times per week (¥122,497±105,660 Yen per six months) was significantly lower than that for PUs cleaned twice a week (¥238,116±60,428 per six months) (p<0.05)., Conclusion: Our results suggest that frequent cleaning of PUs by health professionals in homecare settings not only shorten PU healing period but also reduces care insurance premiums for PU care.

The patient is a 76-year-old man. His chief complaint of chest pain led to a diagnosis of pericardial effusion of unknown cause, and pericardial drainage was performed. On the 30th day, chest pain appeared again. Echocardiography revealed a pericardial fluid reaccumulation and a substantial mass in the pericardial space. Surgical drainage was performed to find the cause. A hematoma/mass was present on the epicardium. The pericardial sac was filled with hematoma. The hematoma was removed, but part of the mass infiltrated close to the anterior descending branch of the left coronary artery, and removal of that part was abandoned. The intrapericardial hematoma and epicardium were submitted to pathology leading to the diagnosis of synovial sarcoma. The patient was discharged home 14 days after surgery.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: Cardiovascular events are increasing in patients with supranormal left ventricular ejection fraction (snLVEF). However, the effect of snLVEF in patients with aortic stenosis (AS) remains unclear, especially in patients with moderate AS., Hypothesis: This study aimed to evaluate the prognosis of mortality and heart failure (HF) in patients with LVEF ≥ 50% and moderate or severe AS., Methods: This retrospective study targeted patients with moderate or severe AS and LVEF > 50%. LVEF of 50%-65% was classified as normal LVEF (nLVEF, nEF group) and >65% as snLVEF (snEF group). AS severity was stratified based on the aortic valve area into moderate (1.0-1.5 cm²) and severe (<1.0 cm²). Primary outcomes included all-cause mortality and HF hospitalization., Results: A total of 226 participants were included in this study. There were 67 and 65 participants with moderate AS in snEF (m-snEF) and nEF groups (m-nEF), respectively, and 41 and 53 participants with severe AS in the snEF (s-snEF) and nEF groups (s-nEF), respectively. During the observation period (median: 554 days), the primary composite outcome occurred in 108 individuals. Cox hazard analysis revealed no significant differences among the four groups in primary composite outcomes. With respect to HF hospitalization, the adjusted hazard ratios (95% confidence intervals) with m-snEF as the reference were as follows: m-nEF, 0.41 (0.19-0.89); s-nEF, 1.43 (0.76-2.67); and s-snEF, 1.83 (1.00-3.35)., Conclusions: The risk of HF hospitalization for m-snLVEF was higher than m-nLVEF and not significantly different from s-nLVEF., (© 2024 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: The fibrosis-4 (FIB-4) index has attracted attention as a predictive factor for cardiovascular events and mortality in patients with heart disease. However, its clinical value in patients with implanted pacemakers remains unclear., Methods: This study included patients who underwent pacemaker implantation. The FIB-4 index was calculated based on blood tests performed during the procedure. The primary outcome was all-cause mortality, and the secondary outcomes included cardiovascular death, non-cardiovascular death, and major adverse cardiovascular events (MACE; composite of cardiovascular death, heart failure hospitalization, non-fatal myocardial infarction, and non-fatal stroke). The FIB-4 index was stratified into tertiles. Between-group comparisons were performed using log-rank tests and multivariate analysis using Cox proportional hazards. The predictive accuracy and cut-off value of the FIB-4 index were calculated from the receiver operating characteristic curve for all-cause mortality. Finally, based on the calculated cut-off values, the patients were divided into two groups for outcome validation and subgroup analysis., Results: This study included 201 participants, of whom 38 experienced death during the observation period (median: 1097 days). All-cause mortality, non-cardiovascular death, and MACE differed significantly between groups stratified by the FIB-4 index tertiles (log-rank test: P<0.001, P<0.001, and P = 0.045, respectively). Using Cox proportional hazards analysis, the unadjusted hazard ratio was 4.75 (95% confidence interval [CI]: 2.05-11.0, P<0.001) for Tertile 3 compared to Tertile 1. After adjustment for confounding factors, including sex, the presence or absence of left bundle branch block at baseline, QRS duration during pacing, and pacing rate at the last check, the hazard ratio was 4.79 (95% CI: 2.04-11.2, P<0.001). The cut-off value of the FIB-4 index was 3.75 (area under the curve: 0.72, 95% CI: 0.62-0.82)., Conclusions: In patients with pacemakers, the FIB-4 index may be a predictor of early all-cause mortality, with a cut-off value of 3.75., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Inoue et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Accurate diagnosis and early resection of colorectal polyps are important to prevent the occurrence of colorectal cancer. However, technical factors and morphological factors of polyps itself can lead to missed diagnoses. Image-enhanced endoscopy and chromoendoscopy (CE) have been developed to facilitate an accurate diagnosis. There have been no reports on visibility using a combination of texture and color enhancement imaging (TXI) and CE for colorectal tumors., Aim: To investigate the visibility of margins and surfaces with the combination of TXI and CE for colorectal lesions., Methods: This retrospective study included patients who underwent lower gastrointestinal endoscopy at the Toyoshima Endoscopy Clinic. We extracted polyps that were resected and diagnosed as adenomas or serrated polyps (hyperplastic polyps and sessile serrated lesions) from our endoscopic database. An expert endoscopist performed the lower gastrointestinal endoscopies and observed the lesion using white light imaging (WLI), TXI, CE, and TXI + CE modalities. Indigo carmine dye was used for CE. Three expert endoscopists rated the visibility of the margin and surface patterns in four ranks, from 1 to 4. The primary outcomes were the average visibility scores for the margin and surface patterns based on the WLI, TXI, CE, and TXI + CE observations. Visibility scores between the four modalities were compared by the Kruskal-Wallis and Dunn tests., Results: A total of 48 patients with 81 polyps were assessed. The histological subtypes included 50 tubular adenomas, 16 hyperplastic polyps, and 15 sessile serrated lesions. The visibility scores for the margins based on WLI, TXI, CE, and TXI + CE were 2.44 ± 0.93, 2.90 ± 0.93, 3.37 ± 0.74, and 3.75 ± 0.49, respectively. The visibility scores for the surface based on WLI, TXI, CE, and TXI + CE were 2.25 ± 0.80, 2.84 ± 0.84, 3.12 ± 0.72, and 3.51 ± 0.60, respectively. The visibility scores for the detection and surface on TXI were significantly lower than that on CE but higher than that on WLI ( P < 0.001). The visibility scores for the margin and surface on TXI + CE were significantly higher than those on CE ( P < 0.001). In the sub-analysis of adenomas, the visibility for the margin and surface on TXI + CE was significantly better than that on WLI, TXI, and CE ( P < 0.001). In the sub-analysis of serrated polyps, the visibility for the margin and surface on TXI + CE was also significantly better than that on WLI, TXI, and CE ( P < 0.001)., Conclusion: TXI + CE enhanced the visibility of the margin and surface compared to WLI, TXI, and CE for colorectal lesions., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Adjuvant durvalumab after chemoradiation has become the standard of care for patients with stage III NSCLC, according to the PACIFIC trial. Whether biomarkers before durvalumab for patients with stage III NSCLC showed predictive and prognostic effects remains unknown., Methods: This is a retrospective study in the Fujieda Municipal General Hospital between October 2018 and March 2022. We assessed the predictive value of the Prognostic Nutritional Index (PNI) in stage III non-small cell lung cancer (NSCLC) patients treated with durvalumab after chemoradiation., Results: After applying the inclusion and exclusion criteria, the study included 56 patients for further analysis. The median follow-up period was 17.6 months (range, 3.0-45.4 months). According to receiver operating characteristic curve results, the PNI cutoff value to predict overall survival (OS) was 37.9, with sensitivity and specificity at 67.9% and 67.9%. Accordingly, the patients were divided into low- and high-PNI groups. Patients with the low-PNI group had a significantly shorter progression-free survival compared to the high-PNI group (median, 9.1 vs. 21.3 months, p  = 0.032). OS was also shorter in the low-PNI group (median, 19.0 months vs. not reached, p  < 0.001). In the multivariate Cox hazards regression analyses, the high-PNI was an independent prognostic factor for OS (hazard ratio, 0.187; 95% confidence interval, 0.046-0.760; p  = 0.019)., It seems that PNI could be used as a predictor for OS in patients with stage III NSCLC treated with durvalumab after chemoradiation.KEY MESSAGESInadequate immunocompetence and nutritional status after chemoradiation therapy may result in poor antitumor efficacy of ICIs.Pretreatment immune and nutritional assessment using PNI could be considered an independent predictor for the survival of stage III NSCLC patients treated with durvalumab after chemoradiation therapy.

Background: Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the urinary albumin-to-creatinine ratio (UACR) in patients with elevated levels of albuminuria in the presence or absence of heart failure (HF) or type 2 diabetes mellitus (T2D). However, these effects have not yet been reported in the presence of both HF and T2D. This lack of evidence prompted us to conduct a clinical trial on the effects of dapagliflozin on UACR in patients with HF and T2D., Methods: DAPPER is a multicentre, randomised, open-labeled, parallel-group, standard treatment-controlled trial that enrolled patients at 18 medical facilities in Japan. Eligible participants with both HF and T2D and aged between 20 and 85 years were randomly assigned to a dapagliflozin or control (anti-diabetic drugs other than SGLT 2 inhibitors) group with a 1:1 allocation. The primary outcome was changes in UACR from baseline after a two-year observation, and secondary endpoints were cardiovascular (CV) events and parameters related to HF. This trial was registered with the UMIN-CTR registry, UMIN000025102 and the Japan Registry of Clinical Trials, jRCTs051180135., Findings: Between 12 May 2017 and 31 March 2020, 294 patients were randomly assigned to the dapagliflozin group (n = 146) or control group (n = 148). The mean age of patients was 72.1 years and 29% were female. The mean glycated hemoglobin value was 6.9%, mean NT-proBNP was 429.1 pg/mL, mean estimated GFR was 65.7 mL/min/1.73 m 2 , and median UACR was 25.0 (8.8-74.6) mg/g Cr in the dapagliflozin group and 25.6 (8.2-95.0) mg/g Cr in the control group. Of the 146 patients in the dapagliflozin group, 122 completed the study, and 107 (87.7%) were taking 5 mg of dapagliflozin daily at the end of the observation period. The primary outcome did not significantly differ between the dapagliflozin and control groups. Among the secondary endpoints, the mean decrease in left ventricular end-diastolic dimensions as one of the echocardiographic parameters was larger in the dapagliflozin group than in the control group. The composite endpoint, defined as CV death or hospitalisation for CV events, hospitalisation for HF events, hospitalisation for all causes, and an additional change in prescriptions for heart failure in a two-year observation, was less frequent in the dapagliflozin group than in the control group., Interpretation: Although dapagliflozin at a dose of 5 mg daily did not reduce urinary albumin excretion in patients with HF and T2D from that in the controls, our findings suggest that dapagliflozin decreased CV events and suppressed left ventricular remodeling., Funding: AstraZeneca KK, Ono Pharmaceutical Co., Ltd., Competing Interests: FY reports grants and personal fees from AstraZeneca K.K. and Ono Pharmaceutical Co., LTD., during the conduct of the study. FY also has received grants from the Japanese government (KAKENHIPROJECT-17K09002, 20K07819, 23K09616) and personal fees from Daiichi Sankyo, National Agricultural Insurance Association, AstraZeneca, Kyowa-Kirin, Bayer, Astellas, Mochida, Teijin, Otsuka, Sumitomo Dainippon, Terumo, Novartis, Akahata, Tanabe Mitsubishi, Boehringer Ingelheim, and Sumitomo, outside the submitted work. MI has nothing to disclose. IS 3) reports grants and personal fees from the National Cerebral and Cardiovascular Centre during the conduct of the study. IS 3) also received grants from Ryukyu University, Soiken Co., Res. Inst. for Production Development and Nexis Co., and personal fees from Daiichi Sankyo, Kowa, AstraZeneca, Kyowa-Kirin, Bayer, Astellas, Mochida, Nipro, Otsuka, Sumitomo Dainippon, Eisai, Novartis, Glaxo Smith Kline, Toa Eiyo, Boehringer Ingelheim, Novo Nordisk, Bristol Myers Squibb, and Sanwa Kagaku, outside the submitted work. YH received grants from the Japanese government (AMED JP20ek0210152, and JP22ek21065) from the National Centre for Global Health and Medicine (21A1001, 21A2004, 21A2007, and 23A1019) and personal fees from AstraZeneca, Daiichi Sankyo, Bayer, Otsuka, Novartis, Tanabe Mitsubishi, Roche, Novo Nordisk, Mochida, Viatris, Kowa, Chugai, MSD, Boehringer Ingelheim, Takeda, Eisai, and Edwards Lifesciences outside the submitted work. HH reports grants and personal fees from AstraZeneca Plc. and Ono Pharmaceutical Co., LTD., during the conduct of the study. HH also received personal fees from Daiichi Sankyo, AstraZeneca, Bayer, and Terumo outside the submitted work. OO has nothing to disclose. CI 6) author, has nothing to disclose. CI 7) author reports grants from the Japanese government (KAKENHIPROJECT-22K08118), AMED (22ek0109539h0002, and 23ek0109629h0001), Daiichi Sankyo, Cannon Medical Systems, Teijin, Pfizer, Idorsia Pharmaceuticals Japan, LSI Medience and Shin Nippon PPD as well as personal fees from Daiichi Sankyo, Edwards Lifesciences, AstraZeneca, Cannon Medical Systems, Bayer, Astellas, Mochida, Teijin, Otsuka, Sumitomo Dainippon, Pfizer, Novartis, Bristol-Myers Squibb, Tanabe Mitsubishi, Boehringer Ingelheim, Tsumura, and MSD outside the submitted work. TN received grants from the Japanese government (KAKENHIPROJECT-22K08223, 22H03191, 21K08044, 20K08483, 20H03681, and 19K08571) and the Japan Agency for Medical Research and Development (AMED: 23811571, 20314990, 21453332, 21472516, and 17930494). TN received personal fees from AstraZeneca, Kyowa-Kirin, Bayer, Astellas, Mochida, Takeda, Otsuka, Sumitomo Dainippon, Boston-Scientific, Novartis, Daiichi Sankyo, Tanabe Mitsubishi, Boehringer Ingelheim, Kowa, Toaeiyo, Bristol Myers Squibb, Gwangju International Interventional Cardiology Symposium (GICS 2023), and Gwangju International Interventional Cardiology Symposium (GICS 2022) outside the submitted work. TS has nothing to disclose. NN has nothing to disclose. KF has nothing to disclose. KI reports honoraria from AstraZeneca, Ono Pharmaceutical, Boehringer Ingelheim, Eli Lilly and Company, Novo Nordisk A/S, Sumitomo Pharma, Amgen, Kowa Company, Bayer, Kyowa-Kirin, Daiichi Sankyo, Astellas, Mochida, Otsuka Pharmaceutical, Novartis, and Tanabe Mitsubishi, and support for attending meetings and travel from Novo Nordisk A/S. OT has nothing to disclose. KK receives personal fees from Otsuka, AstraZeneca, Kyowa-Kirin, Novartis, Amgen, and Abbott. MT received honoraria for lectures from AstraZeneca, Ono Pharmaceutical Co., Kyowa-Kirin, Kowa Company Limited, Sanofi K.K., Daiichi Sankyo, TAISHO PHARMACEUTICAL, Takeda Pharmaceutical, Tanabe Mitsubishi, Boehringer Ingelheim, Novo Nordisk Pharma, Sumitomo Dainippon, MSD, Astellas, Eli Lilly, KISSEI PHARMACEUTICAL, Teijin, Novartis, Mochida, Otsuka, SANWA KAGAKU KENKYUSHO, Sumitomo Pharma, NIPRO CORPORATION, and Bayer. KY received personal fees from Mochida Pharmaceutical Co., Ltd., Eisai Co., Ltd., Otsuka Pharmaceutical, Sanofi, Boston Scientific, Abbott Diagnostics Medical Co., Ltd., Bristol Myers Squibb, DAIICHI SANKYO COMPANY, LIMITED, Nippon Boehringer Ingelheim Co., Ltd., Janssen Pharmaceutical K.K., Kowa Company, Limited, Amgen K.K., Novartis Pharma K.K., AstraZeneca K.K., Edwards Lifesciences, and Mitsubishi Tanabe Pharma Corporation. HT receives personal fees from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Kowa, Mochida, Nippon Shinyaku, Novartis, Omron, Otsuka, PDRadiopharma, and Sumitomo Dainippon outside the submitted work. TH 16) has nothing to disclose. IS 17) reports honoraria from Kyowa-Kirin Terumo, Sumitomo, Novo Nordisk, Eli Lilly, AstraZeneca, Boehringer Ingelheim Sanofi, Otsuka, and MSD. TM receives grants from the Japanese government (KAKENHIPROJECT 18K15864, and 21K16068) and personal fees from Daiichi Sankyo, AstraZeneca, Bayer, Astellas, Mochida, Otsuka, Novartis, and Boehringer Ingelheim outside the submitted work. KW reports consulting fees from Terumo, Gadelius Medical, and ITI Co., LTD., during the conduct of the study. KW also received personal fees from OrbusNeich, Japan Medtronic, Ono Pharmaceutical Co., Daiichi-Sankyo, Dainihon Sumitomo, Amgen, Kowa, Japan Lifeline, Novartis, Toaeiyo, Otsuka Pharma, Mochida, Sumitomo Pharma, Fuji Yakuhin, and AstraZeneca outside the submitted work. KS has nothing to disclose. TH 21) has nothing to disclose. SA has nothing to disclose. SH receives personal fees from Daiichi Sankyo, AstraZeneca, Novartis, Nippon Boehringer Ingelheim, Kowa, Viatris, Actelion, Bayer, Amgen, Bristol Myers, Takeda, Termo, Ono, Janssen, Novo Nordisk, Tanabe, Otsuka, Astellas, and Edwards Lifesciences outside the submitted work. MA received grants from Daiichi Sankyo, Otsuka, Boehringer Ingelheim, and personal fees from AstraZeneca, Tanabe Mitsubishi, Daiichi Sankyo, Novartis, Byer, Boehringer Ingelheim, Nippon Shinyaku, Viatris, Janssen, Astellas, Eli Lilly, and Otsuka outside the submitted work. TK receives Grants-in-Aid for Scientific Research (KAKENHI 22K10547). KO receives personal fees from Nippon Boehringer Ingelheim Co., Ltd., outside the submitted work. SI reports a grant from the Japan Society for the Promotion of Science outside the submitted work. MK reports grants from the Japanese government, grants from the Japan Heart Foundation, grants from the Japan Cardiovascular Research Foundation, personal fees from Daiichi-Sankyo, personal fees from Viatris, grants and personal fees from Ono, grants from Novartis, grants and personal fees from Tanabe-Mitsubishi, grants from Takeda, grants and personal fees from Astra Zeneca, grants and personal fees from Boehringer-Ingelheim, grants from Kowa, and personal fees from Otsuka, and personal fees from Eli Lilly outside the submitted work., (© 2023 The Author(s).)

Aims: The electrical axis shows alterations during right ventricular pacing (RVP), including a normal axis and left axis deviation; however, it remains unknown if differences in the electrical axis affect the occurrence of cardiac adverse events. The purpose of this study was to determine whether a left axis deviation increases the incidence of adverse cardiac events compared with a normal axis., Methods: This study analysed 156 patients with RVP. The patients were divided into two groups: those with left axis deviation after RVP (LAD group) and those with a normal axis (NA group). The primary composite outcome was the new-onset of atrial fibrillation (AF) and worsening heart failure (HF)., Results: The QRS axis of the LAD (n = 77) and NA (n = 79) groups were - 64.5 ± 14.3° and 29.8 ± 36.5°, respectively (P < 0.001). The median follow-up was 1100 days and, regarding primary composite outcomes (hazard ratio, 1.03; 95% confidence interval, 0.64 to 1.65; P = 0.89), 29/77 (37.6%) and 28/79 (35.4%) patients in the LAD and NA groups, respectively, developed AF (hazard ratio, 1.07; 95% confidence interval, 0.64 to 1.81; P = 0.77). Furthermore, 8/77 (10.3%) and 12/79 (15.1%) patients in the LAD and NA groups, respectively, experienced worsening HF (hazard ratio, 0.65; 95% confidence interval, 0.26 to 1.60; P = 0.35)., Conclusion: The risk of cardiac adverse events in patients with RVP (new-onset AF or worsening HF, cardiovascular death, myocardial infarction, and stroke) and overall mortality with LAD is not higher than that with NA., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

This secondary analysis study aimed to detect individual variables that influence the efficacy of monophasic pulsed microcurrent on pressure injury healing. Eleven patients with pressure injuries showing delayed healing underwent a microcurrent stimulation period and a placebo period. We analyzed the correlation between the individual variables and the following three outcomes using monophasic pulsed microcurrent: the wound reduction rate in the electrical stimulation period, the reduction rate in the placebo period, and the difference between these two reduction rates. Furthermore, the patients were divided into two groups, one with a wound reduction rate of more than 10% and the other with less than 10%, and the relationship between each variable was compared. As a result, the wound reduction rate in the electrical stimulation period and the difference in the reduction rate between the two periods showed significant positive correlations with patients' body mass index. In addition, a significant difference was observed in the body mass index between subjects with a reduction rate of 10% or higher and those with a reduction rate of less than 10%. This study found a correlation between the effect of monophasic pulsed microcurrent for pressure injury healing and the level of patients' body mass index.

Introduction: No studies have directly compared postoperative umbilical port site (UPS)-related complications between transumbilical and periumbilical incisions (TUI and PUI) after laparoscopic surgery in children. Patients and Methods: We conducted a retrospective review of 324 children of ≤15 years of age who underwent laparoscopic repair (LR) for inguinal hernia, via either a TUI or PUI, between 2010 and 2020. UPS-related complications, such as wound infection and umbilical deformity, were compared between TUI and PUI. We also investigated the risk factors for the development of UPS-related complications after LR. Results: TUIs and PUIs were used for 228 and 96 children, respectively. The incidence rates of postoperative wound infection and umbilical deformity in the PUI group were higher in comparison to the TUI group; although not to a statistically significant extent (7.3% versus 5.3%, P  = .451, 6.3% versus 4.8%, P  = .593). One case of incisional hernia at the UPS was seen in the TUI group. In the univariate analysis, sex, age, weight for age Z-score, nutrition status, insertion and closure time, total operative time, American Society of Anesthesiologists score, blood loss, and comorbidities were not significantly associated with the development of UPS-related complications after LR. Conclusion: The incidence of UPS-related complications in TUI and PUI was not significantly different. Due to the low incidence of UPS-related complications, it was difficult to draw conclusions regarding contributing factors; however, meticulous care should be taken to avoid UPS-related complications when closing the UPS (Ethical approval No. 2019-24).

Background: The distal hemisphere of a balloon is generally cooled during cryoapplication. However, a wide ablation area can be acquired after cryoballoon ablation. This study aimed to evaluate the extent of ice formation on two types of balloon surfaces through experimental and simulation studies., Methods: A standard cryoballoon (SCB; Arctic Front Advance Pro, Medtronic) and novel cryoballoon (NCB; POLARx, Boston Scientific) were frozen for 240 s in 36 °C normal saline solution to observe ice formation on the balloon surface. Pieces of porcine tissue were placed between the upper and lower sides of the balloon, and the balloon was frozen in the horizontal direction for 240 s in 20 attempts (10 for SCB and NCB each). The measured areas of ice formation were evaluated and compared between the upper and lower sides of each balloon., Results: Ice formation was greater on the lower side of the balloon than on the upper side. A larger area of ice formation in the tissue slab was observed on the lower side than on the upper side in both balloons, and the ice formation extended to the proximal hemisphere on the lower side of the balloon. The ice formation area in the NCB was significantly larger than that in SCB., Conclusions: Ice formation was significantly greater on the lower side of the cryoballoon than on the upper side and extended to the proximal hemisphere of the balloon, which might facilitate the acquisition of a wide ablation area on the left atrial posterior wall after cryoballoon ablation. Different ice formation after cryoballoon ablation Greater ice formation on the lower side of cryoballoon and an extensive ice formation in the proximal hemisphere, especially in novel cryoballoon., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Acute aortic dissection is associated with high mortality and increased risk of complications. Acute exacerbations have a relatively high frequency; however, the contributing factors are unclear. Blood pressure (BP) and heart rate control are important factors, but the ideal BP control strategy to prevent acute exacerbations under invasive arterial pressure monitoring remains unclear. Therefore, in this study, we aimed to determine the relationship between invasive arterial BP and the effects of acute exacerbation of aortic dissection., Methods and Results: This single-centre, retrospective, case-control study included 104 patients with a partial diagnosis of acute aortic dissection (Stanford type A or B) who were treated conservatively between September 2013 and September 2022. The patients were divided into exacerbation (acute exacerbation; n  = 26) and stable (no acute deterioration) groups. The SBP trend (122.5 ± 13.1 vs. 116.6 ± 10.6 mmHg, respectively; P  = 0.024) and mean BP trend (77.8 ± 5.8 vs. 74.4 ± 7.5 mmHg, respectively; P  = 0.038) significantly differed between the two groups. The time to target BP was significantly longer in the exacerbation group ( P  = 0.036)., Conclusion: The exacerbation group did not achieve a mean SBP < 120 mmHg. Moreover, the importance of early BP reduction was demonstrated in the present study., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Acknowledging the extreme risk COVID-19 poses to humans, this paper attempted to analyze and compare case fatality rates, identify the existence of learning curves for COVID-19 medical treatments, and examine the impact of vaccination on fatality rate reduction. Confirmed cases and deaths were extracted from the "Daily Situation Report" provided by the World Health Organization. The results showed that low registration and low viral test rates resulted in low fatality rates, and the learning curve was significant for all countries except China. Treatment for COVID-19 can be improved through repeated experience. Vaccinations in the U.K. and U.S.A. are highly effective in reducing fatality rates, but not in other countries. The positive impact of vaccines may be attributed to higher vaccination rates. In addition to China, this study identified the existence of learning curves for the medical treatment of COVID-19 that can explain the effect of vaccination rates on fatalities.

The concept of complex and high-risk indicated procedures using percutaneous coronary intervention (CHIP-PCI) has recently been defined. However, few studies have investigated the prognosis of patients after CHIP-PCI. We enrolled 322 consecutive patients who underwent CHIP-PCI. CHIP-PCI was defined as a procedure satisfying at least one criterion each for both patient and procedure characteristics, as follows: patient characteristics [age ≥ 75 years old, low left ventricular ejection fraction (LVEF), diabetes mellitus, acute coronary syndrome, previous coronary artery bypass surgery, peripheral arterial disease, severe chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and severe valvular disease] and procedure characteristics [unprotected left main disease, degenerated saphenous or radial artery grafts, severely calcified lesions, last patent conduit, chronic total occlusions, multivessel disease, and use of mechanical circulatory support]. On Kaplan-Meier analysis, 1-, 2-, and 3-year survival rates following CHIP-PCI was 93.8%, 89.2%, and 85.4%, respectively. Moreover, on Cox multivariate hazard analysis, age (≥ 75 years old) (hazard ratio: 4.01, 95% confidence interval: 1.92-8.38, P < 0.01), COPD (hazard ratio: 2.95, 95% confidence interval: 1.38-6.32, P < 0.01), low LVEF (hazard ratio: 3.35, 95% confidence interval: 1.55-7.22, P < 0.01), severe CKD (hazard ratio: 3.02, 95% confidence interval: 1.44-6.36, P < 0.01), and use of mechanical circulatory support (hazard ratio: 5.97, 95% confidence interval: 2.72-13.10, P < 0.01) remained significant predictors of mortality. In conclusion, we revealed the clinical outcomes after CHIP-PCI. The presence of advanced age, COPD, low LVEF, severe CKD, and mechanical circulatory support use might lead to worse clinical outcomes.

Background: Prognosis of nephrotic syndrome has been evaluated based on pathological diagnosis, whereas its clinical course is monitored using objective items and the treatment strategy is largely the same. We examined whether the entire natural history of nephrotic syndrome could be evaluated using objective common clinical items., Methods: Machine learning clustering was performed on 205 cases from the Japan Nephrotic Syndrome Cohort Study, whose clinical parameters, serum creatinine, serum albumin, dipstick hematuria, and proteinuria were traceable after kidney biopsy at 5 measured points up to 2 years. The clinical patterns of time-series data were learned using long short-term memory (LSTM)-encoder-decoder architecture, an unsupervised machine learning classifier. Clinical clusters were defined as Gaussian mixture distributions in a two-dimensional scatter plot based on the highest log-likelihood., Results: Time-series data of nephrotic syndrome were classified into four clusters. Patients in the fourth cluster showed the increase in serum creatinine in the later part of the follow-up period. Patients in both the third and fourth clusters were initially high in both hematuria and proteinuria, whereas a lack of decline in the urinary protein level preceded the worsening of kidney function in fourth cluster. The original diseases of fourth cluster included all the disease studied in this cohort., Conclusions: Four kinds of clinical courses were identified in nephrotic syndrome. This classified clinical course may help objectively grasp the actual condition or treatment resistance of individual patients with nephrotic syndrome., (© 2022. The Author(s).)

A continuous-flow quaternization reaction of gramines with MeI (<1 min) followed by a substitution reaction with a chiral nucleophilic glycine-derived Ni-complex ( S )-2 (<1 min) has successfully been developed to afford the corresponding alkylated Ni-complexes 3 in good yields with excellent diastereoselectivity, based on the results of a one-pot quaternization-substitution reaction of gramines with ( S )-2 in a batch process. The continuous-flow process allowed the safe and efficient scale-up synthesis of 3j (84% yield, 99% de, 540 g h -1 ) to give 7-azatryptophan derivative ( S )-4j readily by an acid-catalyzed hydrolysis reaction followed by protection with an Fmoc group. The present method for the rapid and efficient syntheses of enantiopure unnatural tryptophan derivatives from various gramines and ( S )-2 will be useful to further promote peptide and protein drug discovery and development research.

Purpose: In aortic stenosis (AS), the discrepancy between moderately accelerated flow and effective orifice area (EOA) continues to pose a challenge. We developed a method of measuring the vena contracta area as hemodynamic EOA using cardiac MRI focusing on AS patients with a moderately accelerated flow to solve the problem that AS severity can currently be determined only by echocardiography., Methods: We investigated 40 patients with a peak transvalvular velocity > 3.0 m/s on transthoracic echocardiography (TTE). The patients were divided into highly accelerated and moderately accelerated AS groups according to whether or not the peak transvalvular velocity was ≥ 4.0 m/s. From the multislice 2D cine phase-contrast MRI data, the cross-sectional area of the vena contracta of the reconstructed streamline in the Valsalva sinus was defined as MRI-EOAs. Patient symptoms and echocardiography data, including EOA (defined as TTE-EOA), were derived from the continuity equation using TTE., Results: All participants in the highly accelerated AS group (n = 19) showed a peak velocity ≥ 4.0 m/s in MRI. Eleven patients in the moderately accelerated AS group (n = 21) had a TTE-EOA < 1.00 cm 2 . In the moderately accelerated AS group, MRI-EOAs demonstrated a strong correlation with TTE-EOAs (r = 0.76, P < 0.01). Meanwhile, in the highly accelerated AS group, MRI-EOAs demonstrated positivity but a moderate correlation with TTE-EOAs (r = 0.63, P = 0.004). MRI-EOAs were overestimated compared to TTE-EOAs. In terms of the moderately accelerated AS group, the best cut-off value for MRI-EOAs was < 1.23 cm 2 , compatible with TTE-EOAs < 1.00 cm 2 , with an excellent prediction of the New York Heart Association classification ≥ III (sensitivity 87.5%, specificity 76.9%)., Conclusion: MRI-EOAs may be an alternative to conventional echocardiography for patients with moderately accelerated AS, especially those with discordant echocardiographic parameters.

Rationale: The relationship between rheumatoid arthritis (RA) and eosinophilic inflammation is unclear. According to recent studies, it has been suggested that T helper 2 cell responses play a role in the inhibition of RA. It is unclear how the immunological response after coronavirus disease-2019 (COVID-19) vaccination affects T cell immune reactions., Patient Concerns and Diagnoses: Here, we report the case of an 88-year-old woman diagnosed with RA and chronic eosinophilic pneumonia (CEP). She was diagnosed with CEP about 20 years ago, and, through steroid treatment, she improved and had no relapse for 16 years. At the time of diagnosis of CEP, the rheumatoid factor (RF) was increased; however, there were no joint symptoms. After receiving the COVID-19 vaccine, joint and respiratory symptoms gradually worsened. Laboratory examinations showed increased RF, anti-cyclin citrullinated peptide antibody, and peripheral absolute eosinophil count. Musculoskeletal ultrasonography showed synovitis., Intervention and Outcome: Methylprednisolone pulse therapy improved respiratory and joint symptoms immediately; RA and CEP stabilized with no relapses., Lessons: Eosinophilic and rheumatoid reactions following COVID-19 vaccination were an-reported adverse events. Eosinophilic inflammation might be reflected on an anti-inflammatory reaction in initial phase of RA., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

SMTP (the name SMTP is derived from Stachybotrys microspora triprenyl phenol) is a family of triprenyl phenol secondary metabolites from a black mold, Stachybotrys microspora . Some SMTP congeners exhibit anti-inflammatory and profibrinolytic activities that, in combination, contribute to the treatment of ischemic stroke. The final step in the SMTP biosynthesis is a non-enzymatic amine conjugation with an o -phthalaldehyde moiety of the precursor pre-SMTP, which can form adducts with proteins and nucleic acids. Thus, pre-SMTP formation should be a precisely regulated, rate-limiting step in the SMTP biosynthesis. To address the mechanism backing this regulation, we purified a metabolite that rapidly disappeared following amine feeding, identifying a novel compound, pri-SMTP. Furthermore, an enzyme, designated as pri-SMTP oxidase, responsible for pri-SMTP conversion to pre-SMTP, was purified. The formation of pri-SMTP, which is regulated by nitrogen and carbon nutrients, occurred in particular septate mycelia. Although pri-SMTP oxidase was expressed constitutively, the consumption of pri-SMTP was accelerated only when a primary amine was fed. Thus, SMTP biosynthesis is regulated by at least three mechanisms: (i) pri-SMTP formation affected by nutrients, (ii) the compartmentalization of pri-SMTP formation/storage, and (iii) amine-regulated pri-SMTP oxidation. Amine-regulated SMTP formation (i.e., amine-capturing with pre-SMTP) may play a role in the nitrogen acquisition/assimilation strategy in S. microspora , since pri-SMTP synthesis occurs on non-preferred nitrogen.

Objectives: This double-blind crossover-controlled trial aimed to verify the effect of electrical stimulation therapy on pressure injuries with undermining., Methods: : In this trial, we compared the healing rates between a sham period and a treatment period using monophasic pulsed microcurrent therapy. The participants were randomly assigned to the sham or treatment group and received stimulation for 2 weeks. All the participants, physical therapists, and researchers were blinded to the allocation. For the main analysis, data on the effect of the intervention on changes in weekly healing and contraction rates of the wound areas, including undermining, were analyzed based on a two-period crossover study design. The intervention effect was estimated by examining the mean treatment difference for each period using Wilcoxon's signed-rank test., Results: : The reduction of the entire wound area, including the undermining area, resulted in significantly higher healing and contraction rates in the treatment group (overall wound area reduction rate: contraction rate, P=0.008; period healing rate, P=0.002)., Conclusions: : Electrical stimulation therapy for pressure injuries, using conditions based on the findings of an in vivo culture study, was effective in reducing the wound area., Competing Interests: CONFLICTS OF INTEREST: The authors have no conflicts of interest to declare., (2022 The Japanese Association of Rehabilitation Medicine.)

Introduction: Extracorporeal membrane oxygenation (ECMO) and Continuous renal replacement therapy (CRRT) are treatments for critically ill patients with respiratory failure and acute kidney injury. However, no reliable factors have been identified to predict survival in patients treated with both ECMO and CRRT. The aim of this study was to identify prognostic factors for discharging intensive care unit (ICU) patients who required CRRT during ECMO., Methods: We retrospectively analyzed data from patients who required CRRT in addition to the ECMO, between April 2015 and March 2018. The patients were divided into two groups: patients who survived and patients who died during ICU hospitalization. We determined their demographic and clinical characteristics, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, Simplified Acute Physiology Score II (SAPS II) scores, and sequential organ failure assessment (SOFA) scores. Further, we assessed whether these characteristics differed between individuals who did or did not survive the ICU hospitalization., Results: We found that the APACHE II and SAPS II scores differed significantly between both ECMO and CRRT treated patients who did or did not survive hospitalization. Further, intracranial hemorrhage during ECMO and CRRT therapy was associated with lower survival rate., Conclusions: Using APACHE II and SAPS II scores might be helpful in making treatment decisions for patients treated with ECMO and CRRT. Intracranial hemorrhage could be a poor prognostic factor. Our findings indicate the potential utility of APACHE II and SAPS II scores to predict mortality in patients treated with both ECMO and CRRT.

Background: Percutaneous intervertebral-vacuum polymethylmethacrylate injection (PIPI) is a minimally invasive procedure for low back pain in elderly patients with degenerative lumbar scoliosis (DLS). Patients with DLS often have radiculopathy as a result of foraminal stenosis in addition to low back pain. The purpose of this study was to evaluate the clinical and radiologic results of PIPI for foraminal stenosis with radiculopathy in elderly patients with DLS., Methods: We included patients with de novo DLS aged 65 years or older who underwent PIPI. The presence of an intervertebral vacuum on computed tomography and bone marrow edema on magnetic resonance imaging was required for inclusion. The intersegmental radiologic parameters on plain radiographs and computed tomography and the extent of bone marrow edema on magnetic resonance imaging were measured. The clinical outcomes were evaluated using the visual analog scale (VAS) and Oswestry Disability Index (ODI)., Results: We enrolled 40 patients with DLS who underwent PIPI. There were 16 men and 24 women, and the mean age was 79.0 ± 6.3 years. The mean foraminal height and extent of bone marrow edema showed a significant increase and reduction, respectively, after PIPI (P < 0.05). VAS score for radiculopathy and ODI significantly improved after PIPI (P < 0.01). The minimum clinically important differences in VAS score for radiculopathy and ODI at the final follow-up were 73.9% and 63.6%, respectively., Conclusions: PIPI is a minimally invasive procedure not only for low back pain but also for radiculopathy in elderly patients with DLS. It leads to intervertebral stabilization and indirect decompression of the foramen., (Copyright © 2022. Published by Elsevier Inc.)

This paper provides descriptions of two new theridiosomatid species, Theridiosomanigrivirgatum sp. nov. and Sennintanikawai gen. nov. , sp. nov. from the Ryukyu Islands, southwest Japan, with photographs and illustrations of both sexes. Sennin gen. nov. is a troglophilic genus composed of two species, S.tanikawai sp. nov. (Iriomote Island, Japan) and S.coddingtoni Suzuki, Serita & Hiramatsu, 2020, and comb. nov. Suzuki, Serita & Hiramatsu, 2020 with their habitat types, web morphology, and web-building behavior in detail.Zomadibaiyin Miller, Griswold & Yin, 2009, which recently joined the Japanese fauna, was morphologically reexamined based on specimens from the Ryukyus, and taxonomic features of Zoma males were reassessed. A distributional map of theridiosomatid spiders in the Ryukyus is also provided, including T.dissimulatum Suzuki, Serita & Hiramatsu, 2020, and T.alboannulatum Suzuki, Serita & Hiramatsu, 2020 with their habitat types, web morphology, and web-building behavior in detail., (Yuya Suzuki, Takehisa Hiramatsu, Haruki Tatsuta.)

Previous studies reported conflicting results regarding an association between serum albumin concentration and the cumulative incidence of remission of proteinuria in adult patients with minimal change disease (MCD). The present study aimed to clarify the clinical impact of serum albumin concentration and the cumulative incidence of remission and relapse of proteinuria in 108 adult patients with MCD at 40 hospitals in Japan, who were enrolled in a 5-year prospective cohort study of primary nephrotic syndrome, the Japan Nephrotic Syndrome Cohort Study (JNSCS). The association between serum albumin concentration before initiation of immunosuppressive treatment (IST) and the cumulative incidence of remission and relapse were assessed using multivariable-adjusted Cox proportional hazards models. Remission defined as urinary protein < 0.3 g/day (or g/gCr) was observed in 104 (96.3%) patients. Of 97 patients with remission within 6 month of IST, 42 (43.3%) developed relapse defined as ≥ 1.0 g/day (or g/gCr) or dipstick urinary protein of ≥ 2+. Serum albumin concentration was significantly associated with remission (multivariable-adjusted hazard ratio [95% confidence interval] per 1.0 g/dL, 0.57 [0.37, 0.87]), along with eGFR (per 30 mL/min/1.73 m 2 : 1.43 [1.08, 1.90]), whereas they were not associated with relapse. A multivariable-adjusted model showed that patients with high eGFR level (≥ 60 mL/min/1.73 m 2 ) and low albumin concentration (≤ 1.5 g/dL) achieved significantly early remission, whereas those with low eGFR (< 60 mL/min/1.73 m 2 ) and high albumin concentration (> 1.5 g/dL) showed significantly slow remission. In conclusion, lower serum albumin concentration and higher eGFR were associated with earlier remission in MCD, but not with relapse., (© 2022. The Author(s).)

Background: To determine the optimal treatment for spontaneous spinal epidural hematoma (SSEH). The aim of this study was to identify factors associated with SSEH., Methods: In 62 patients with SSEH, several patient-related parameters were analyzed as candidate factors associated with Frankel grade before treatment or at the last follow-up. These parameters were compared between patients with and without surgery. In addition, multivariate ordinal logistic regression analysis was used to identify factors significantly associated with Frankel's grade before treatment or at the last follow-up., Results: There were significant differences in age, location of the hematoma, and Frankel grade before treatment and at the last follow-up between surgical and nonsurgical cases in all patients, but there were no significant differences in any of these parameters when comparing patients with pre-treatment Frankel grade C. The location of the hematoma was significantly associated with the severity of paralysis before treatment. In surgical cases, the time from onset to surgery and the location of the hematoma was significantly associated with the prognosis. When the time from onset to surgery was evaluated using the criteria of 12, 24, and 48 h, 24 and 48 h had a significant impact on the prognosis. In the analysis of nonsurgical cases, only the vertical size of the hematoma was significantly associated with prognosis., Conclusion: The time from onset to surgery and the location of the hematoma were prognostic factors in surgical cases, while the vertical size of the hematoma was a prognostic factor in nonsurgical cases., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

In cryoballoon ablation (CBA), a contrast medium is commonly used to confirm balloon occlusion of the pulmonary veins (PVs). However, a contrast medium cannot always be used in patients with renal dysfunction and allergy. The present study aimed to assess the efficacy and safety of CBA without the use of a contrast medium. We retrospectively examined consecutive patients with paroxysmal atrial fibrillation (PAF) who underwent first-time CBA. We compared the procedural results and outcomes in patients for whom a contrast medium was used (contrast group) and those from whom a contrast medium was not used (non-contrast group). In the non-contrast group, we used saline injection on the intracardiac echocardiography and pressure wave monitoring for PV occlusion. Fifty patients (200 PVs) and 22 patients (88 PVs) underwent CBA with and without a contrast medium, respectively. The success rate of PV isolation with CBA alone was 93% and 90% in the non-contrast and contrast groups, respectively (p = 0.40). The fluoroscopy time and nadir temperature were significantly lower in the non-contrast group as compared to that in the contrast group. The recurrence rate 1 year after ablation did not differ between the two groups (18% vs. 18%, p > 0.99). Furthermore, the number of reconnected PVs in patients with recurrence was significantly lower in the non-contrast group than in the contrast group (6% vs. 36%, p = 0.017). In conclusion, CBA using the intracardiac echocardiography and pressure monitoring approach without the use of a contrast medium was safe and efficient., (© 2021. Springer Japan KK, part of Springer Nature.)

Background: Minimal change disease (MCD) is characterized by a nephrotic syndrome usually steroid-sensitive and a high incidence of relapse of proteinuria. Previous cohort studies have reported conflicting results regarding the association between the time to remission and incidence of relapse., Methods: This multicenter prospective cohort study included 102 adult patients with steroid-sensitive MCD or focal segmental glomerulosclerosis from a 5-year cohort study of primary nephrotic syndrome, the Japan Nephrotic Syndrome Cohort Study, who achieved remission of proteinuria within 2 months of immunosuppressive therapy (IST). The association between the time to remission of proteinuria after immunosuppressive therapy and incidence of relapse was assessed using Cox proportional hazards models adjusted for clinically relevant factors., Results: Remission was observed at 3-7, 8-14, 15-21, 22-28, and 30-56 days after initiation of immunosuppressive therapy in 17 (16.7%), 37 (36.3%), 21 (20.6%), 13 (12.7%), and 14 (13.7%) patients, respectively. During a median observation period of 2.3 years after the end of the 2nd month after initiation of immunosuppressive therapy, 46 (45.1%) patients relapsed. The time to remission was associated with the incidence of relapse in an inverse U-shaped pattern (multivariable-adjusted hazard ratios [95% confidence intervals] of the time to remission of 3-7, 8-14, 15-21, 22-28, 30-56 days: 1.00 [reference], 1.76 [0.56, 5.51], 6.06 [1.85, 19.80], 5.46 [1.44, 20.64], and 2.19 [0.52, 9.30], respectively)., Conclusion: The time to remission was identified as a significant predictor of relapse in steroid-sensitive patients., (© 2022. The Author(s) under exclusive licence to Italian Society of Nephrology.)

Introduction: Considerable debate exists regarding the benefits of laparoscopic percutaneous extraperitoneal closure (LPEC) over conventional open repair (OR). We assessed the outcomes and feasibility of LPEC compared to OR for pediatric inguinal hernia (IH)., Methods: We retrospectively analyzed 570 children who underwent LPEC or OR. Parents decided the operative method after obtaining informed consent. Patient characteristics, operative time, complications and contralateral metachronous IH (CMIH) were compared between the groups., Results: A total of 329 children underwent LPEC and 241 underwent OR. There was no significant difference in the incidence of recurrence or testicular ascent between the LPEC and OR groups (0.3% vs 0.4%, P = 0.825, 0.3% vs 0.8%, P = 0.391, respectively). No testicular atrophy was recognized in either group. One patient with postoperative chronic inguinal pain was recognized in each group. There was no surgical site infection (SSI) in the OR group; however, the LPEC group more frequently demonstrated umbilical port site (UPS)-related complications, such as incisional hernia, minor deformity, granuloma formation, cellulitis and superficial SSI. Ten (4.1%) developed CMIH in OR; in contrast, no case of CMIH was experienced after LPEC (P < 0.001)., Conclusion: In conclusion, both LPEC and OR are feasible in the management of pediatric IH, because of their high success rates and low risk of complications. LPEC could be the superior procedure with respect to the prevention of CMIH. However, to maximize the merits of LPEC over OR, it is important to reduce UPS-related complications in LPEC. A longer follow-up is needed to assess male fertility in patients who receive LPEC., (© 2021 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

We report a fatal case of methicillin-resistant Staphylococcus aureus (MRSA)-induced necrotizing pneumonia that was refractory to adequate vancomycin treatment (trough value, 13.1 µg/ml), drainage of hydropneumothorax, and veno-arterial extracorporeal membrane oxygenation. Despite appropriate treatment, MRSA infection can cause rapidly progressive disease with a high-case fatality rate., Competing Interests: None declared., (© 2022 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

We report here the case of a 92-year-old woman with atrial fibrillation bradycardia in which leadless pacemaker implantation was performed with a difficult delivery of the catheter sheath due to an extremely large right atrium. Using a snare technique with correction of the direction of the force on the catheter toward the right ventricle (RV) can result in successful delivery of the pacemaker catheter and stable placement of the pacemaker system in the RV septum. This specific snare technique has the potential to facilitate leadless pacemaker implantation safely in a severely dilated chamber of the heart, making this technique effective to use in clinical practice.

Introduction: With regard to short-term outcome in atrial fibrillation (AF), the benefit of cryoballoon ablation (CBA) by pressing a balloon against the earliest pulmonary vein (PV) potential site during PV isolation (earliest potential [EP]-guided CBA) has been previously demonstrated. The present study aimed to evaluate the long-term outcome of the EP-guided CBA., Methods and Results: This study included 136 patients from two randomized studies, who underwent CBA for paroxysmal AF for the first time. Patients were randomly assigned to the EP-guided and conventional CBA groups in each study. In the EP-guided CBA group, we pressed a balloon against the EP site when the time-to-isolation (TTI) after cryoapplication exceeded 60 and 45 s in the first and second studies, respectively. We compared the clinical outcomes for 1 year after the procedure between the EP-guided CBA group (68 patients) and the conventional CBA group (68 patients). The primary endpoint was the recurrence of atrial arrhythmia after ablation. No significant differences in baseline characteristics were observed between the two groups. Compared with the conventional CBA group, the EP-guided CBA group had a significantly higher success rate at TTI ≤ 90 s (98.5% vs. 90.0%, p < .001); lower touch-up rate and total cryoapplication; and shorter procedure time, and fluoroscopy time. The recurrence at 1 year after ablation was significantly lower in the EP-guided CBA group than in the conventional CBA group (6.0% vs. 19.4%; p = .019)., Conclusions: The EP-guided CBA approach can facilitate the ablation procedure and achieve low recurrence at 1 year after ablation., (© 2021 Wiley Periodicals LLC.)

Introduction: Balloon kyphoplasty (BKP) is a minimally invasive surgical approach for the treatment of osteoporotic vertebral fractures (OVF). Some risks have been reported after treatment with BKP; therefore, it is necessary to determine when BKP does not work. Thus, in this study, we aim to clarify the radiographic predictors of secondary vertebral fractures and cement loosening after BKP for OVF., Methods: This study enrolled patients with single-level OVF at the thoracolumbar junction (T11-L2) who underwent BKP for the first time between January 2011 and March 2014. The clinical outcomes were evaluated using the visual analog scale (VAS) and a modified Oswestry Disability Index (ODI) at 1 week and 1, 3, 6, and 12 months after surgery. Radiographic assessments were performed preoperatively and within 1 year after BKP using plain radiography and computed tomography., Results: The 85 patients who met the inclusion criteria underwent BKP. The average age of participants (21 men, 64 women) was 77.8 years (range, 57-92 years). Postoperative VAS and ODI scores were all significantly better than preoperative scores. Polymethyl methacrylate (PMMA)-cement leakage was observed in 18 patients (21.2%) but was asymptomatic in all cases. Secondary vertebral fractures were detected in 20 patients (23.5%), including adjacent levels in 15 patients (17.6%) and non-adjacent levels in 5 patients (5.9%). Rostral bridging osteophyte formation was found to be significantly associated with the occurrence of adjacent vertebral fractures (odds ratio 12.746; p =0.010). PMMA-cement loosening was observed in three patients (3.5%). A high prevalence (100%) of bridging osteophytes, vacuum clefts, and spinous process fractures was observed in patients with PMMA-cement loosening. PMMA-cement loosening was found in 3 out of 10 patients with all three of these factors., Conclusions: Rostral bridging osteophyte formation was determined to be a risk factor for both adjacent vertebral fractures and PMMA-cement loosening., Level of Evidence: 3., Competing Interests: Conflicts of Interest: The authors declare that there are no relevant conflicts of interest., (Copyright © 2022 by The Japanese Society for Spine Surgery and Related Research.)

Background: FOLFOX therapy, a standard treatment for colorectal cancer (CRC), causes a rare, but serious adverse event, hyperammonemia. However, the risk factors of hyperammonemia remain unknown., Methods: We examined 74 patients who received mFOLFOX6 therapy with or without biologics for CRC between April 2013 and March 2018 in Yaizu City Hospital. Clinicopathological factors were retrospectively reviewed in association with hyperammonemia, and risk factors of hyperammonemia during mFOLFOX6 therapy were analyzed in 32 patients with the available data., Results: Seven patients developed hyperammonemia, with onset exclusively on day 2 or 3 in the first cycle of therapy. They were treated with branched chain amino acid administration and hydration; however, one patient with stage G4 chronic kidney disease (CKD) died. By multivariate analysis, estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m 2 was independently associated with hyperammonemia during FOLFOX therapy (odds ratio: 9.0, p = 0.040)., Conclusions: Reduced eGFR is considered a risk factor of developing hyperammonemia during FOLFOX therapy. Serum ammonia levels should be monitored especially during the first cycle of FOLFOX therapy in patients with CKD stage G3 or higher., (© 2021. Japan Society of Clinical Oncology.)

Purpose: Treatment of low back pain (LBP) associated with elderly degenerative lumbar scoliosis (DLS) remains controversial. We have developed percutaneous intervertebral-vacuum polymethylmethacrylate injection (PIPI) targeting to the intervertebral vacuum as a minimally invasive surgery. The present study compared the long-term clinical outcomes of PIPI to that of nonoperative treatment., Methods: Patients with de novo DLS, aged ≥ 65 years, who had LBP with visual analog scale (VAS) of ≥ 50 for ≥ 6 months with intervertebral vacuum on computed tomography and bone marrow edema (BME) on magnetic resonance imaging were included. The clinical outcomes were evaluated using VAS and the Oswestry Disability Index (ODI) at baseline, 1, 6, 12, 24 months, and at the final follow-up. The course of BME was also evaluated., Results: One hundred and one patients underwent PIPI and 61 received nonoperative treatment. The mean follow-up duration after PIPI and nonoperative treatment was 63.7 ± 32.4 and 43.9 ± 20.9 months, respectively. VAS and ODI after PIPI were significantly improved compared to post-nonoperative treatment. BME decreased substantially in the PIPI group and it was significantly correlated with VAS and ODI improvement. Following PIPI, LBP recurred in 28 patients (35%). LBP recurrence was identified at the same level of PIPI in 10 patients, at the adjacent level of PIPI in 11 patients, and at the non-adjacent level of PIPI in seven patients. Eighteen patients underwent additional PIPIs, and both VAS and ODI were significantly improved after additional PIPIs., Conclusion: Bone marrow lesions of the endplate are strongly associated with the presence of LBP. PIPI can be considered as an effective, safe and repeatable treatment for LBP in elderly DLS patients., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The Clinical Frailty Scale (CFS) is a simple tool to assess patients' frailty and may help to predict adverse outcomes in elderly patients. The aim of the present study was to examine the impact of CFS on clinical outcomes and bleeding events after successful percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI). We enrolled 266 consecutive patients with STEMI who underwent primary PCI in between January 2015 and June 2018. Patients were categorized into two groups based on the CFS stages: CFS 1-3 and CFS ≥ 4. We collected the data and evaluated the relationship between the CFS grade and the incidence of major adverse cardiovascular events (MACE) and Bleeding Academic Research Consortium 3 or 5 bleeding events. Of these patients, CFS ≥ 4 was present in 59 (22.2%). During the follow-up, 37.3% in the CFS ≥ 4 group and 8.2% in the CFS 1-3 group experienced MACE. In Kaplan-Meier analysis, the proportion of MACE-free survival for 4 years was significantly lower in the CFS ≥ 4 group (log-rank P < 0.001). Additionally, the proportion of bleeding event-free survival was significantly lower in the CFS ≥ 4 group (log-rank P < 0.001). The CFS (per 1-grade increase) remained an independent significant predictor of MACE on multivariate Cox proportional hazard analysis [hazard ratio 1.39 (95% confidence interval: 1.08 to 1.79, P = 0.01)]. In conclusion, CFS was an independent predictor of future adverse cardiac events in patients with STEMI. Therefore, the assessment of CFS is crucial in this population.

Background : Assistive use of short-acting β2 agonists (SABAs) reportedly improves exercise tolerance, activities of daily living, and health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD). However, the effect of SABA on physical activity (PA) is unclear. Objective : This study aimed to determine whether assistive use of SABA increases PA and whether additional pulmonary rehabilitation (PR) can aid further improvement. Methods : Twelve outpatients with COPD and dyspnea during daily activities despite regular use of long-acting bronchodilators were enrolled. This study comprised a 2-week pre-intervention investigation, a 12-week investigation of SABA effects, and an 8-week investigation of the additional effects of PR. Assistive use of SABA was allowed up to 4 times per day after the pre-intervention period. PA was measured for 14 consecutive days using an accelerometer sensor. Dyspnea, exercise tolerance, and HRQOL were evaluated at entry, at 4 and 12 weeks after initiating SABA use, and after completing PR. Results : Assistive use of SABA improved breathlessness during daily activities and increased PA ( p < .001). PA and HRQOL were also improved following PR ( p < .001 and p = .013, respectively). Conclusions : Combined therapy of SABA and PR can increase PA and HRQOL in COPD patients.

Rationale: Hormone therapies, particularly those targeting estrogen and its receptors, are a key treatment modality for patients with estrogen receptor (ER)-positive breast or ovarian cancer. Some gastric cancers (GCs) express ERs, and preclinical studies suggest the potential of estrogen-targeting hormone therapy on GC; however, the clinical relevance of this hormone therapy on GC treatment has not been well elucidated., Patient Concerns: An 80-year-old female was admitted to our department with hypogastric pain and vomiting. Computed tomography demonstrated small bowel obstruction, and laparotomy after bowel decompression revealed peritoneal dissemination consisting of a poorly-differentiated adenocarcinoma. Intestinal bypass between the ileum and transverse colon was performed., Diagnoses: The tumor was ER- and mammaglobin-positive, indicating that it originated from a breast cancer. Diagnostic imaging revealed no evidence of breast cancer; however, right axillary ER- and mammaglobin-positive lymphadenopathy was found., Interventions: The patient received hormone therapy using letrozole based on a clinical diagnosis of occult breast cancer with peritoneal dissemination and right axillary lymph node metastasis., Outcomes: The patient remained disease free until 37 months but deceased at 53 months from the onset of disease. An autopsy revealed no tumor cells in the right breast tissue; however, there was a massive invasion of cancer cells in the stomach., Lessons: A patient with ER positive GC with peritoneal dissemination and right axillary lymph node metastasis presented remarkable response to letrozole. The long-term survival obtained using letrozole for a patient with GC with distant metastasis suggests the potential of estrogen targeting hormone therapies for GC., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)