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We examined the cross-sectional association between intake of carotenoids with provitamin A activity and carotid artery plaques in 12,773 participants of the Atherosclerosis Risk in Communities Study aged 45-64 y. Usual diet was assessed with a 66-item food-frequency questionnaire. Plaques were examined by B-mode ultrasound of multiple carotid artery segments. In both women and men, those in the highest quintile of carotenoid consumption had a lower prevalence of plaques (women, 25.4%; men, 36.0%) than those in the lowest quintile of carotenoid consumption (women, 29.3%; men, 39.8%). The prevalence odds ratios contrasting extreme intake quintiles were 0.82 (95% CI: 0.70, 0.97) in women and 0.85 (95% CI: 0.72, 1.01) in men. The associations diminished slightly after potential confounders were adjusted for. In women, the inverse association was particularly strong for current smokers (adjusted odds ratio contrasting extreme quintiles: 0.67; 95% CI: 0.45, 0.98). In men, no such effect modification by smoking was seen. The inverse association was somewhat stronger in men aged 55-64 y than in those aged 45-54 y, whereas age made little difference in women. These findings, together with previous findings that carotenoid intake was unrelated to average carotid artery wall thickness, suggest that carotenoids may exert their influence later rather than earlier in the atherosclerotic process, and support the hypothesis that carotenoids or other plant-derived compounds may play a role in preventing arterial plaque formation. Copyright (c) 1998 American Society for Clinical Nutrition [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID19) can cause gastrointestinal complications as well as respiratory tract disease. Coagulation abnormalities and thrombosis frequently occur in COVID19, especially in cases with severe clinical outcome. The relationship between gastrointestinal perforation and coagulopathy due to COVID19 remains unclear., Case Presentation: A 49-year-old female received Chimeric antigen receptor T (CAR-T) therapy for an early recurrence of diffuse large B-cell lymphoma (DLBCL) that was refractory to chemotherapy. She was diagnosed with cytokine release syndrome (CRS) because of a fever and oxygen desaturation, and administered tocilizumab. Forty days after completing CAR-T therapy, she was infected with COVID19 and transferred to our hospital. Her general condition worsened and she developed COVID19 pneumonia, and then steroid pulse therapy was started. While her respiratory condition improved, she experienced pain in the anal region and computed tomography (CT) revealed a rectal perforation. An emergency surgery was undertaken, and the lower rectum wall was found to be completely necrotic. Removal of the necrotic part of the rectum tissue, and drainage and lavage of necrotic tissue in the pelvic cavity were performed. The remaining rectum was resected with partial sigmoidectomy, but we could not make the anal stump closed. In addition, an end colostomy in the sigmoid colon was performed. Histopathological findings showed thromboses in the rectal mesentery veins. After the first surgery, the pelvic abscess cavity persisted and her high-grade fever continued. Reoperation was laparoscopically performed, and she underwent a resection of anal canal with residual necrotic rectal and mesorectal tissue, and a drainage of the pelvic abscess. After the reoperation, her general condition improved and CT showed that the abscess cavity had significantly improved., Conclusions: Gastrointestinal perforation, especially rectal necrosis due to coagulopathy caused by severe COVID19 infection, is a rare but life-threatening complication. Physicians should have a high degree of clinical suspicion for timely diagnosis and management, and surgical intervention is necessary in cases of rectal necrosis., (© 2024. The Author(s).)

Competing Interests: Declaration of competing interest One of the authors declares financial competing interests from Olympus Terumo Biomaterials and AUSPICIOUS.

Background: Perioperative factors are useful for predicting postoperative infectious complications (PIC) in gastric cancer. Specifically, postoperative inflammatory response indicators (PIRI), [C-reactive protein (CRP) level, body temperature (BT), and white blood cell (WBC) count], are widely used in clinical practice. We investigated predictive factors for PIC, including PIRI, to establish a simple and practical indicator of postoperative complications after gastrectomy., Methods: We retrospectively collected clinical data from 200 patients with fStage I-III gastric cancer. Univariate/multivariate analysis was performed to evaluate the relationship of predictive factors [host factors, clinicopathological factors, and PIRI (BT, WBC count, and CRP level on postoperative day (POD) 1 and 3) ]. Cut-off values of the predictive factors were analyzed using receiver operating characteristic (ROC) curve modulated by the presence/absence of PIC Grade II, III (Clavien-Dindo classification)., Results: Age [Odds ratio (OR): 5.67], smoking history (OR: 3.51), and CRP level (OR: 5.65), WBC count (OR: 8.96), and BT (OR: 3.37) on POD3 were selected as independent factors from multivariate analysis. Cut-off values were 77 years, 14.8 mg/dL, 116.0×10 2 /μL, and 37.4°C, respectively., Conclusions: Predictive factors relative to PIC in gastric cancer were CRP level ≥ 14.8 mg/dL, WBC count ≥ 116.0×10 2 /μL, and BT ≥ 37.4°C all on POD3. Age ≥ 77 years, and history of smoking were relative to PIC, suggesting a simple and practical indicator applicable in clinical practice.

Dearomatization of pyridines is a well-established synthetic approach to access piperidines. Although remarkably powerful, existing dearomatization processes have been limited to the hydrogenation or addition of carbon-based nucleophiles to activated pyridiniums. Here, we show that arenophile-mediated dearomatizations can be applied to pyridines to directly introduce heteroatom functionalities without prior substrate activation. The arenophile platform in combination with olefin oxidation chemistry provides access to dihydropyridine cis -diols and epoxides. These previously elusive compounds are now readily accessible and can be used for the downstream preparation of diversely functionalized piperidines.

Background: Alcoholic steatohepatitis and nonalcoholic steatohepatitis-related liver cirrhosis (ASH/NASH-LC) are major causes of esophageal varices (EVs). However, the association between high visceral fat and exacerbation of EVs remains unclear. The aim of this study was to clarify the association of visceral fat and recurrence rate of EVs in ASH/NASH-LC and to identify independent predictors associated with recurrence., Methods: We retrospectively evaluated data from 94 patients who underwent endoscopic injection sclerotherapy for EVs with ASH/NASH-LC. Using the receiver operating characteristic curve for the cut-off value of visceral fat index (VFI; 46.4 cm 2 /m 2 ), we classified patients as having a high VFI (n = 53) or low VFI (n = 41). Propensity score matching was used to align for background factors, and the recurrence rate of EVs was compared between the two groups. Predictors associated with esophageal variceal recurrence were identified by multivariate analysis. The recurrence rate in patients with viral LC was also investigated., Results: In the overall analysis, the recurrence rate was significantly higher in the high VFI group than in the low VFI group (P = 0.023). The recurrence rate was also higher in the high VFI group than in the low VFI group after propensity score matching, in which 19 patients were matched in each group (P = 0.048). VFI and Child-Pugh score were independently associated with recurrence. Recurrence rates were comparable between the two groups in viral LC patients., Conclusions: Worsening of variceal recurrence was observed in high visceral fat patients in ASH/NASH-LC but not in viral LC. Furthermore, high visceral fat was an independent predictor associated with variceal recurrence.

Background: The incidence of alcoholic liver cirrhosis (ALC) is increasing. However, few reports have focused on ALC-derived esophageal varices (EV). We retrospectively examined differences in overall survival (OS) and EV recurrence rate in patients after endoscopic injection sclerotherapy (EIS) for ALC and hepatic B/C virus liver cirrhosis (B/C-LC)., Methods: We analyzed data from 215 patients (B/C-LC, 147; ALC, 68) who underwent EIS. The primary endpoints were OS and EV recurrence in patients with unsuccessful abstinence ALC and those with uncontrolled B/C-LC, before and after propensity score matching (PSM) to unify the patients' background. The secondary endpoints were predictors associated with these factors, as determined by multivariate analysis., Results: The observation period was 1,430 ± 1,363 days. In the analysis of all patients, OS was significantly higher in the ALC group than in the B/C-LC group (p = 0.039); however, there was no difference in EV recurrence rate (p = 0.502). Ascites and history of hepatocellular carcinoma (HCC) (p = 0.019 and p < 0.001, respectively) predicted OS, whereas age and EV size predicted recurrence (p = 0.011 and 0.024, respectively). In total, 96 patients without an HCC history were matched by PSM, and there was no significant difference in OS or EV recurrence rate (p = 0.508 and 0.246, respectively)., Conclusion: When limited to patients without a history of HCC, OS and the EV recurrence rate were comparable in patients with ALC who continued to consume alcohol and those with B/C-LC without viral control.

A 27-year-old woman was diagnosed with idiopathic thrombocytopenic purpura in the neonatal period, and was admitted to our hospital after presenting with impaired consciousness, purpura, nausea and vomiting, with a platelet count of 10×10 9 /l. Congenital thrombotic thrombocytopenic purpura (cTTP) was suspected on the basis of recurrent thrombocytopenia and impaired consciousness, so tests for ADAMTS13 activity and inhibitor were performed. ADAMTS13 activity was severely decreased, ADAMTS13 inhibitor was negative, and platelet count increased after transfusion of fresh frozen plasma. These findings and the results of genetic testing done on all family members led to a diagnosis of cTTP. cTTP requires differential diagnosis even in adults. If a patient diagnosed with ITP in childhood has a history or findings that suggest cTTP during follow-up observation, it is necessary to actively consider ADAMTS13 testing.

We experienced a case of diffuse large B-cell lymphoma(DLBCL)that developed around the kidney about 1 year after surgery for sigmoid colon cancer. In this case, imaging findings suggestive of liver metastasis were also observed at the same time of diagnosis, therefore, diagnosis was difficult because the possibility of peritoneal dissemination could not be ruled out. The lesion was excised by surgery and a definitive diagnosis was obtained by tissue diagnosis, leading to appropriate treatment. However, one wrong step could lead to the wrong treatment policy. Therefore, when there is any doubt about the diagnosis, it is considered important to proactively perform tissue diagnosis.

Background/aim: Recent studies have reported that the C-reactive protein (CRP) to albumin ratio (CAR) may be a useful prognostic biomarker in various types of cancer patients. However, the mechanism underlying this observation is unclear. The present study aimed to clarify why the CAR can predict post-esophagectomy prognosis, the relationship between pre- and postoperative CAR, and whether postoperative CAR can predict the prognosis of esophageal cancer patients., Patients and Methods: We investigated 158 esophagectomy patients with esophageal squamous cell carcinoma. Hematological examinations were performed on postoperative days (POD) 1, 3, 5, 7, 10, and 14., Results: Preoperative CAR was a significant independent prognostic factor of overall survival (OS) [hazard ratio (HR)=2.247; p=0.0005], and there was a strong correlation between preoperative CAR and tumor depth. The preoperative high-CAR (pre-high-CAR) group had significantly higher CAR on all postoperative days (POD). We then divided the patients as follows: those with at least two low-CAR days on POD 5, 7, and 10 were assigned to the modified post-low-CAR (mPost-low-CAR) group, and others were assigned to the modified post-high-CAR (mPost-high-CAR) group. The 5-year OS rate was significantly higher in the mPost-low-CAR group than in the mPost-high-CAR group, which predicted a more accurate prognosis (p<0.0001, HR=2.769)., Conclusion: Preoperative CAR was associated with tumor depth and diameter, and patients in the pre-high-CAR group continued to have significantly higher CAR postoperatively. These factors were presumed to reflect disease prognosis. Furthermore, grouping by CAR on POD 5, 7, and 10 reflected patient prognosis more accurately than preoperative CAR., (Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objective: To evaluate the current status and postoperative course of nutritional management in bridge to surgery(BTS) after colorectal stenting for malignant colorectal stenosis., Subjects and Methods: The study included 242 colorectal cancer cases, 27 cases with malignant colorectal stenosis who underwent BTS group, 24 cases with malignant colorectal stenosis who fasted until the day of surgery and consumed drinking water and Elenthal®(no oral intake group), and 191 cases with non-stenotic colorectal cancer (diet group). The study items selected were nutritional management methods before colorectal cancer resection, nutritional assessment, surgical factors, and postoperative course., Results: The BTS, no oral intake, and diet groups were compared in 27, 0, and 191 patients, respectively. In contrast, the intake of Elenthal® was compared in 4, 20, and 5 patients and total parenteral nutrition in 3, 15, and 1 patients, respectively. There were no differences in nutritional sufficiency during hospitalization. The Onodera Nutritional Index(PNI)was significantly lower in the BTS and no oral intake groups than the diet group at the first outpatient visit before surgery. The PNI was significantly lower in the no oral intake group than in the diet group immediately before surgery. Blood loss was higher in the BTS and no oral intake groups than in the diet group, but there was no difference in operative time. The postoperative course was poorer in the no oral intake group than in the diet group. However, there was no difference between the diet and BTS groups., Conclusion: In patients with obstructive colorectal cancer in whom BTS could be performed, the results suggest that preoperative nutritional management with a high sufficiency rate using the intestinal tract may lead to a postoperative course comparable to that in non-stenotic cases.

Medial meniscal posterior root tears disrupt the "hoop" function of the meniscus and may lead to knee osteoarthritis. Although root repair could be a key to osteoarthritis prevention, this surgery does not necessarily guarantee an optimal result even when combined with meniscal centralization and high tibial osteotomy. To address this issue, we made five modifications to the original combined approach, namely two anchors to fix the root, instead of one; bridging centralization instead of single centralization; release of the meniscotibial capsule vs no release; release of valgus stress before knot tying vs no release; and prohibiting postoperative cross-legged sitting and sitting on heels. The advantages of this approach over the original approach are numerous and comprise ease of performing concurrent open wedge high tibial osteotomy, shorter fixation distance, better anatomical reattachment of the meniscal root, increased bone-meniscus contact and contact pressure, and larger contact area between the capsule and tibial rim. The disadvantages of the approach are that knot-tying is cumbersome, pie-crusting of the medial collateral ligament is necessary in patients not undergoing open wedge high tibial osteotomy, and tears >3 mm from the attachment are a contraindication. We describe the steps in this modified approach in detail., (© 2023 The Authors.)

Patellar subluxation and recurrent dislocation are commonly treated with medial patellofemoral ligament reconstruction, and patients with predisposing factors for these problems often require additional bony realignment procedures. However, these procedures mainly address problems in the axial plane, and patients with medial-compartmental knee osteoarthritis may require further realignment in the coronal plane. In this Technical Note article, we introduce our technique for derotational hybrid closed-wedge high tibial osteotomy. Using this technique, simultaneous 3-dimensional realignment in the axial, coronal, and sagittal planes can be achieved in patients with medial compartmental knee osteoarthritis and patellar subluxation caused by a tibial torsional deformity. The indications for the technique and the preoperative planning assessments involving a static torsional deformity analysis on computed tomography images and a dynamic gait analysis by our walking-on-paper method are presented. This is followed by a detailed description of the surgical procedure, together with consideration of the pearls and pitfalls of the procedure. A video of the surgery performed in a representative case with medial knee osteoarthritis and patellar subluxation in the right knee owing to an outward tibial torsion deformity is also provided., (© 2023 The Authors.)

Background: Totally extraperitoneal (TEP) repair is a recommended procedure for inguinal hernia repair in European hernia guidelines. However, technical challenges have limited its uptake in Japan, where transabdominal preperitoneal (TAPP) repair is more common. We evaluated the association of preoperative subcutaneous fat area (preSFA) with surgical outcomes and identified factors associated with the difficulty of TEP repair., Methods: Clinical data from 62 patients undergoing TEP repair were collected retrospectively. Using the median for the preoperative subcutaneous fat index (preSFI; 45.9 cm 2 /m 2 ), we classified patients as having a high SFI (HSFI) (n=31) and low SFI (LSFI) (n=31). Surgical outcomes and perioperative complications were then compared between these groups. Additionally, TEP repair was divided into five phases (e.g., Phase 1: dissection of the caudal side of the preperitoneal space), and operative time was measured during each phase. Phase 1 was divided into two sub-phases (1A: insertion of the first port, 1B: reaching Cooper's ligament)., Results: Operative time was longer (133 min vs 111 min, P = 0.028) and the peritoneal injury rate was higher (35.5% vs 9.7%, P = 0.015) for the HSFI patients. Furthermore, operative time for HSFI patients was significantly longer during Phase 1 (P = 0.014) and Phase 1A (P = 0.022)., Conclusions: preSFA was associated with a higher peritoneal injury rate and longer operative time in HSFI patients, suggesting that the presence of abundant subcutaneous fat increases the difficulty of TEP repair.

Puberuline C ( 1 ) is an architecturally complex C 19 -diterpenoid alkaloid with a unique ring fusion pattern. The 6/7/5/6/6/6-membered rings (ABCDEF-rings) contain one tertiary amine and six oxygen functionalities, and possess 12 contiguously aligned stereocenters, three of which are quaternary. These structural features of 1 make its chemical construction exceptionally challenging. Here, we disclose the first total synthesis of 1 . The synthesis was accomplished from 2-cyclohexenone ( 9 ) by integrating radical cascade and Mukaiyama aldol reactions as the key transformations. A double Mannich reaction fused the A- and E-rings, and Sonogashira coupling attached the C-ring, efficiently leading to ACE-rings with the requisite 19 carbons of 1 . The chemically stable tertiary chloride of the ACE-ring structure was then transformed to the corresponding bridgehead radical, which participated in the simultaneous cyclization of the B- and F-rings via a highly organized radical cascade process. This unusual step installed five contiguous stereocenters, including two quaternary carbons, without damaging the preexisting multiple polar functionalities. Subsequently, the intramolecular Mukaiyama aldol reaction between silyl enol ether and acetal was realized by applying a combination of SnCl 4 and ZnCl 2 , forging the last remaining D-ring of the hexacycle. Finally, 3 was elaborated into 1 through regio- and stereoselective functionalizations of the BCD-rings. Our novel radical-based strategy achieved the total synthesis of 1 in 32 total steps from simple 9 , demonstrating the power of the radical cascade reaction to streamline the assembly of highly complex molecules.

Objective: To describe the incidence of injuries and illnesses sustained during the Tokyo Summer Olympic Games from 23 July to 8 August 2021., Methods: We recorded the daily number of athlete injuries and illnesses (1) through the reporting of all National Olympic Committee (NOC) medical teams and (2) in the polyclinic and medical venues by the Tokyo 2020 medical staff., Results: In total, 11 315 athletes (5423 women, 48%; 5892 men, 52%) from 206 NOCs were followed up prospectively for the occurrence of injury and illness. NOC and Tokyo 2020 medical staff reported 1035 injuries and 438 illnesses, equalling 9.1 injuries and 3.9 illnesses per 100 athletes over the 17-day period. Altogether, 9% of the athletes incurred at least one injury and 4% at least one illness. The incidence of injury was highest in boxing (27%), BMX racing (27%), BMX freestyle (22%), skateboarding (21%), karate (19%) and handball (18%), of which both BMX freestyle and skateboarding were new events, and lowest in diving, road cycling, rowing, marathon swimming and shooting (1-2%). Marathon and artistic swimming presented the highest illness incidences (both 8%), followed by skateboarding and karate (both 7%). In the study period, COVID-19 affected 18 athletes, accounting for 4% of all illnesses and 0.16% of all athletes. Exertional heat illness affected 78 athletes (18% of all illnesses, 0.7% of all athletes), the majority (88%) resulting in no time lost from sport., Conclusion: Overall, 9% of the athletes incurred an injury and 4% an illness during the Games. Comprehensive countermeasures helped mitigate both COVID-19 and exertional heat illnesses., Competing Interests: Competing interests: TSo works as scientific manager in the Medical and Scientific Department of the International Olympic Committee. KS is co-editor of the British Journal of Sports Medicine – Injury Prevention & Health Protection. MM is deputy editor of the British Journal of Sports Medicine. RB is director of the Medical and Scientific Department of the International Olympic Committee. LE is head of scientific activities in the Medical and Scientific Department of the International Olympic Committee, and editor of the British Journal of Sports Medicine and associate editor of the Journal of Bone and Joint Surgery., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)