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Abstract The nursing practice environment is essential for improving the quality of nursing practice and patient service. Performing secondary analysis of data from the work environment for hospital nurses in Japan (WENS-J) study, this research investigated whether an improved, healthier work environment could enhance nurses’ psychological empowerment. Self-administered questionnaire responses of 2,438 participants from 23 participating general hospitals with over 200 beds in municipalities with a population of 200,000 or more were analyzed. The questionnaire recorded participating nurses’ demographic characteristics and utilized two scales: the Practice Environment Scale of the Nursing Work Index (PES-NWI) and the Psychological Empowerment Instrument (PEI), which identified adequate work environments and measured the internalization of organizational goals and objectives, respectively. Most participants (93.7%) were female nurses with a mean age of 33.7 years. Multilevel analysis (hierarchical linear models) revealed that the total PEI score was significantly related to the PES-NWI composite score and all subscales after adjusting for nurses’ demographic characteristics, such as age (coefficient 0.33–0.72, all p

Abstract Background In Japan, the Endoscopic Surgical Skill Qualification System (ESSQS) is used to evaluate surgical skills essential for laparoscopic surgery, but whether surgeons with this certification as operators improve the short‐term outcomes and prognosis after rectal cancer surgery is unclear. This cohort study was designed to compare the short‐term and long‐term outcomes of laparoscopic surgery for advanced rectal cancer performed by an ESSQS‐certified surgeon versus a surgeon without ESSQS certification. Methods The outcomes of cStage II and III rectal cancer surgery cases performed at 56 Japanese hospitals between 2014 and 2016 were retrospectively reviewed. To examine the impact of ESSQS‐certified surgeons as surgeons, the outcomes of cases with only ESSQS‐certified surgeons as operators were compared with those without involvement of ESSQS‐certified surgeons. Results A total of 3197 cases were enrolled, with 1015 in which surgery was performed by ESSQS‐certified surgeons, and 544 in which there was no involvement of ESSQS‐certified surgeons. After propensity score matching, the ESSQS group had significantly shorter operative time (p

Background/objective: This study aimed to clarify the kinematics of bi-cruciate-retaining (BCR) total knee arthroplasty (TKA) by comparing the mechanical alignment (MA) and functional alignment (FA) methods and to evaluate differences between the two alignment methods. Methods: The in vivo kinematics of 20 MA TKA and 20 FA TKA knees were investigated under fluoroscopy during squatting using a two-to three-dimensional registration technique. Accordingly, knee flexion angle, axial rotational angle, varus–valgus angle, anteroposterior translation of the medial and lateral low contact points of the femoral component relative to the tibial component and kinematic pathway were evaluated. Results: No difference in the knee flexion angle was observed between the MA and FA TKA groups. Femoral external rotation was observed in both groups and no significant difference was observed. Significant varus alignment from extension to early flexion range was observed in the FA TKA group. The posterior translation of the medial side was smaller in the FA TKA group than in the MA TKA group. Conversely, no significant difference in the anteroposterior translation of the lateral side was observed. In the kinematic pathway, a medial pivot motion from 0° to 20° of flexion and a lateral pivot motion beyond 20° of flexion were observed in both groups. Conclusion: During squatting in BCR TKA, the FA TKA group significantly showed varus alignment and smaller posterior translation of the medial side than the MA TKA group from extension to early flexion range.

Abstract Aim The coronavirus disease 2019 (COVID‐19) pandemic greatly impacted medical resources such as cancer screening, diagnosis, and treatment given to people for various diseases. We surveyed the impacts of the pandemic on the incidence of complications and mortality following pancreaticoduodenectomy for pancreatic cancer in Japan. Methods Data on patients who underwent pancreaticoduodenectomy for pancreatic cancer were extracted from the Japanese National Clinical Database (NCD) between 2018 and 2021. The number of the pancreaticoduodenectomy for pancreatic cancer were obtained and then the morbidity and mortality rates were evaluated using a standardized morbidity/mortality ratio (SMR), which is the ratio of the observed number of incidences to the expected number of incidences calculated by the risk calculator previously developed by the NCD. Results This study included 22 255 cases. The number of pancreaticoduodenectomies exhibited an increasing trend even during the COVID‐19 pandemic. The mean observed incidence rates of Grade C pancreatic fistula and Clavien–Dindo grade ≥4 complications, and the 30‐day mortality and surgical mortality rates were 0.8%, 1.8%, 0.8% and 0.9%, respectively. The standardized morbidity ratios did not increase during the COVID‐19 pandemic. The standardized mortality ratios remained within the range of variations observed before the COVID‐19 pandemic. Conclusion The increasing trend in the number of pancreaticoduodenectomies and favorable short‐term outcomes even in the COVID‐19 pandemic suggest the medical care for pancreatic cancer in Japan functioned well during the pandemic.

Abstract Aim We evaluated the morbidity and mortality associated with liver surgery in Japan and developed a risk model for liver resection using information from a national database. Methods We retrospectively reviewed 73 861 Japanese patients who underwent hepatectomy between 2014 and 2019, using information from the National Clinical Database (NCD) registrations. The primary endpoints were 30 days and in‐hospital mortality, and the secondary endpoints were postoperative complications. Logistic regression risk models for postoperative morbidity and mortality after hepatectomy were constructed based on preoperative clinical parameters and types of liver resection, and validated using a bootstrapping method. Results The 30‐day and in‐hospital mortality rates were 0.9% and 1.7%, respectively. Trisectionectomy, hepatectomy for gallbladder cancer, hepatectomy for perihilar cholangiocarcinoma, and poor activities of daily living were statistically significant risk factors with high odds ratios for both postoperative morbidity and mortality. Internal validations indicated that the c‐indices for 30‐day and in‐hospital mortality were 0.824 and 0.839, respectively. Conclusions We developed a risk model for liver resection by using a national surgical database that can predict morbidity and mortality based on preoperative factors.

Abstract Background Due to the coronavirus disease 2019 (COVID‐19) pandemic, cancer screening, diagnosis, and treatment have changed. This study aimed to investigate the impact of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection prior to gastroenterological cancer surgeries on postoperative complications using data from a nationwide database in Japan. Methods Data on patients who underwent surgery for cancer including esophageal, gastric, colon, rectal, liver, and pancreatic cancer between July 1, 2019, and September 300, 2022, from real‐world sources in Japan were analyzed. The association between preoperative SARS‐CoV‐2 infection and short‐term postoperative outcomes was evaluated. A similar analysis stratified according to the interval from SARS‐CoV‐2 infection to surgery (4 weeks) was conducted. Results In total, 60 604 patients were analyzed, and 227 (0.4%) patients were diagnosed with SARS‐CoV‐2 infection preoperatively. The median interval from SARS‐CoV‐2 infection to surgery was 25 days. Patients diagnosed with SARS‐CoV‐2 infection preoperatively had a significantly higher incidence of pneumonia (odds ratio: 2.05; 95% confidence interval: 1.05–3.74; p = 0.036) than those not diagnosed with SARS‐CoV‐2 infection based on the exact logistic regression analysis adjusted for the characteristics of the patients. A similar finding was observed in patients who had SARS‐CoV‐2 infection

Abstract Aim To examine the potential negative effects of the COVID‐19 pandemic on short‐term postoperative outcomes of emergency surgery for gastroduodenal perforation in Japan. Methods A total of 7973 cases of gastroduodenal perforation from 2019 to 2021 were retrieved from the National Clinical Database (NCD), which includes >95% of surgical cases in Japan. Data were analyzed nationally and in subgroups for subjects in areas with high infection levels (HILs). Postoperative 30‐d mortality, surgical mortality, and complications (Clavien–Dindo (CD) grade ≥3) were examined. Months were considered to have significantly high or low mortality or complication rates, if the 95% confidence interval (CI) of the standardized mortality (morbidity) ratio (SMR) does not contain 1. Results Nationally, data from 2019 vs 2020 and 2021 showed 30‐d mortality of 175 (6.7%) vs 398 (7.4%), surgical mortality of 250 (9.5%) vs 537 (10.1%), and complications (CD ≥3) of 558 (21.2%) vs 1163 (21.8%). Among these data, the only significantly high SMR was found for complications in July 2020 (1.36 [95% CI: 1.001–1.80]). In areas with HILs, data from 2019 vs 2020 and 2021 indicated 30‐d mortality of 91 (6.3%) vs 215 (7.3%), surgical mortality of 135 (9.4%) vs 294 (10.0%), and complications (CD ≥3) of 304 (21.1%) vs (23.1%). In these data, no month had a significantly high SMR. Conclusion The COVID‐19 pandemic had few negative effects on outcomes after surgery for gastroduodenal perforation. These findings suggest that the emergency system for gastroduodenal perforation in Japan was generally maintained during the pandemic.

Purpose: In vivo kinematics of skeletal joints and prostheses is affected by gravity; therefore, absolute tilt must be taken into account. However, current fluoroscopic kinematic analysis cannot measure the tilt. This study introduces and validates a method for defining the horizontal plane in fluoroscopy systems to measure the tilt of an object. Methods: A rectangular metal plate (200 ​× ​200 ​× ​10 ​mm) with a flatness of 0.03/100 ​mm was horizontally adjusted using a leveler (sensitivity of 0.02° and accuracy of ±0.06°), and its three-dimensional coordinate was calculated from a two-dimensional fluoroscopic image. A coordinate calculation formula was developed, with precision and accuracy assessed via computer simulations. Actual fluoroscopic tests included four aspects: accuracy under the same condition; accuracy under different X-ray tube height; reproducibility when changing X-ray tube height; and reproducibility when the flat panel was tilted and returned. Results: The theoretical measurement error indicated by the computer simulations was 0.0 ​± ​0.2° on the xy-plane and 0.0 ​± ​0.0° on the yz-plane. The actual experimental results showed that the horizontal plane tilt was measured to be −0.2 ​± ​0.1° tilt on the xy-plane and 0.3 ​± ​0.0° tilt on the yz-plane for the device used in this study. The F-test showed no significant differences between the computer simulations and the actual experiments. There were no significant differences between the four actual tests. Conclusions: This method enables the horizontal plane to be defined and the tilt of an object to be measured in fluoroscopic kinematic analysis.

For maxillary gingival carcinomas, especially those in the molar region, surgical resection is often performed beyond the maxillary tuberosity. Bleeding from the posterior superior alveolar or maxillary artery into the pterygoid process is difficult to stop during partial maxillary resection. Advances in catheterization and materials have enabled the embolization of various vessels. In this report, we describe two cases of maxillary gingival cancer in which preoperative endovascular arterial embolization prevented bleeding due to unexpected vascular injury, allowing for a safe surgery with minimal blood loss. This technique effectively avoids emergency hemostasis for unexpected bleeding when resecting gingival cancers in the maxillary molar region.

Abstract Background Janus kinase (JAK) inhibitors, such as baricitinib, are widely used to treat rheumatoid arthritis (RA). Clinical studies show that baricitinib is more effective at reducing pain than other similar drugs. Here, we aimed to elucidate the molecular mechanisms underlying the pain relief conferred by baricitinib, using a mouse model of arthritis. Methods We treated collagen antibody-induced arthritis (CAIA) model mice with baricitinib, celecoxib, or vehicle, and evaluated the severity of arthritis, histological findings of the spinal cord, and pain-related behaviours. We also conducted RNA sequencing (RNA-seq) to identify alterations in gene expression in the dorsal root ganglion (DRG) following baricitinib treatment. Finally, we conducted in vitro experiments to investigate the direct effects of baricitinib on neuronal cells. Results Both baricitinib and celecoxib significantly decreased CAIA and improved arthritis-dependent grip-strength deficit, while only baricitinib notably suppressed residual tactile allodynia as determined by the von Frey test. CAIA induction of inflammatory cytokines in ankle synovium, including interleukin (IL)-1β and IL-6, was suppressed by treatment with either baricitinib or celecoxib. In contrast, RNA-seq analysis of the DRG revealed that baricitinib, but not celecoxib, restored gene expression alterations induced by CAIA to the control condition. Among many pathways changed by CAIA and baricitinib treatment, the interferon-alpha/gamma, JAK-signal transducer and activator of transcription 3 (STAT3), and nuclear factor kappa B (NF-κB) pathways were considerably decreased in the baricitinib group compared with the celecoxib group. Notably, only baricitinib decreased the expression of colony-stimulating factor 1 (CSF-1), a potent cytokine that causes neuropathic pain through activation of the microglia–astrocyte axis in the spinal cord. Accordingly, baricitinib prevented increases in microglia and astrocytes caused by CAIA. Baricitinib also suppressed JAK/STAT3 pathway activity and Csf1 expression in cultured neuronal cells. Conclusions Our findings demonstrate the effects baricitinib has on the DRG in relation to ameliorating both inflammatory and neuropathic pain.

Thoracic outlet syndrome (TOS) is characterized by intractable cervicobrachial pain caused by strangulation of the brachial plexus and subclavian artery by structures of the superior thoracic outlet. We describe percutaneous epidural adhesiolysis for refractory pain due to TOS. A man in his 40s had received nerve block therapy for right upper extremity pain of unknown origin for 5 years. Although imaging findings were negative for TOS, reproducible pain relieved by injection of a local anesthetic into the anterior scalene muscle suggested TOS due to compression by the muscle. Subsequently, since nerve block treatment had only temporary effect and the pain gradually worsened, right T1 epidural adhesiolysis was performed. Thereafter, the pain improved from a numerical rating scale score of 8-9/10 to 2-3/10, continuing for about 3 months. Epidural adhesiolysis was remarkably effective in treating intractable pain caused by TOS due to strangulation of the brachial plexus by the anterior scalene muscle.

IntroductionSleep disorders are common in the general population, necessitating the search for new strategies to address this public health challenge. The study aims to describe the electrocorticographic and behavioral changes in sleep deprived Wistar rats exposed to varying doses of camphor, to assess its effects on sleep and its potential as a sleep-inducing drug.Materials and MethodsFor the electrocorticographic evaluation, seventy-two rats were randomly assigned to distinct groups: a control group, a sleep-deprived group, three sleep-deprived groups receiving 10, 20, and 30 mg/kg i.p. of camphor respectively, and three groups that received these doses without sleep deprivation. For the behavioral analysis, twenty-seven rats were divided into three groups, each receiving the same doses as the previous test.Results and DiscussionOur results showed that there was a decrease in the frequency of brain oscillatory patterns when camphor was administered at 10 mg/kg i.p. whereas there was a dose-dependent increase in the spectral power and distribution following the administration of 20 and 30 mg/kg i.p., with the emergence of Delta, Theta, Alpha, and Beta waves. As for the behavioral analysis, it was demonstrated that testicular relaxation, decreased motility, and light sleep induction also occurred in a dose-dependent manner. Thus, we conclude that camphor administration intensifies occipital electrocorticographic patterns in sleep-deprived rats, and its electrocorticographic and behavioral analysis could indicate a potential as a supporting agent in the insomnia treatment.

Summary: The gut microbiota influences physiological functions of the host, ranging from the maintenance of local gut homeostasis to systemic immunity and metabolism. Secreted phospholipase A2 group X (sPLA2-X) is abundantly expressed in colonic epithelial cells but is barely detectable in metabolic and immune tissues. Despite this distribution, sPLA2-X-deficient (Pla2g10−/−) mice displayed variable obesity-related phenotypes that were abrogated after treatment with antibiotics or cohousing with Pla2g10+/+ mice, suggesting the involvement of the gut microbiota. Under housing conditions where Pla2g10−/− mice showed aggravation of diet-induced obesity and insulin resistance, they displayed increased colonic inflammation and epithelial damage, reduced production of polyunsaturated fatty acids (PUFAs) and lysophospholipids, decreased abundance of several Clostridium species, and reduced levels of short-chain fatty acids (SCFAs). These obesity-related phenotypes in Pla2g10−/− mice were reversed by dietary supplementation with ω3 PUFAs or SCFAs. Thus, colonic sPLA2-X orchestrates ω3 PUFA-SCFA interplay via modulation of the gut microbiota, thereby secondarily affecting systemic metabolism.

Abstract Aim Possible negative effects of the COVID‐19 pandemic on short‐term postoperative outcomes for colorectal perforation in Japan were examined in this study. Methods The National Clinical Database (NCD) is a large‐scale database including more than 95% of surgical cases in Japan. We analyzed 13 107 cases of colorectal perforation from 2019 to 2021. National data were analyzed, and subgroup analyses were conducted for subjects in prefectures with high infection levels (HILs) and metropolitan areas (Tokyo Met. and Osaka Pref.). Postoperative 30‐day mortality, surgical mortality, and postoperative complications (Clavien–Dindo grade ≥3) were examined. Months were considered to have significantly high or low mortality or complication rates, if the 95% confidence interval (CI) of the standardized mortality (morbidity) ratio (SMR) does not contain 1. Results In the NCD, postoperative 30‐day mortality occurred in 1371 subjects (10.5%), surgical mortality in 1805 (13.8%), and postoperative complications in 3950 (30.1%). Significantly higher SMRs were found for 30‐day mortality in November 2020 (14.6%, 1.39 [95% CI: 1.04–1.83]) and February 2021 (14.6%, 1.48 [95% CI: 1.10–1.96]), and for postoperative complications in June 2020 (37.3%, 1.28 [95% CI: 1.08–1.52]) and November 2020 (36.4%, 1.21 [95% CI: 1.01–1.44]). The SMRs for surgical mortality were not significantly high in any month. In prefectures with HILs and large metropolitan areas, there were few months with significantly higher SMRs. Conclusions The COVID‐19 pandemic had limited negative effects on postoperative outcomes in patients with colorectal perforation. These findings suggest that the emergency system for colorectal perforation in Japan was generally maintained during the pandemic.

Abstract Background A technical qualification system was developed in 2004 by the Japan Society for Endoscopic Surgery. An analysis of the EnSSURE study on 3188 stage II–III rectal cancer patients, which was performed by including the participation of qualified surgeons as assistants and advisers without restricting their participation as operators, revealed that the participation of technically qualified surgeons in surgery improved the technical and oncological safety of laparoscopic rectal resection. Aim This secondary retrospective analysis of the EnSSURE study examined the advantage of qualified surgeons participating in laparoscopic low anterior resection (LAR). Methods The outcomes of low anterior resection were compared between groups with and without the participation of surgeons qualified by the Endoscopic Surgical Skill Qualification System (Q and non‐Q groups, respectively). We used propensity score matching to generate paired cohorts at a one‐to‐one ratio. The postoperative complication rate, short‐term results (hemorrhage volume, operative time, number of dissected lymph nodes, open conversion rate, intraoperative complication rate, and R0 resection rate), and long‐term results (disease‐free survival rate, local recurrence rate, and overall survival rate) were evaluated. Results The frequencies of postoperative complications, anastomotic bleeding, and intraperitoneal abscess were significantly lower, the operative time was significantly shorter, the postoperative hospital stay was significantly shorter, and the number of dissected lymph nodes was higher in the Q group. No significant differences were observed in disease‐free survival, local recurrence, or overall survival rate rates between the groups. Conclusion The participation of qualified surgeons in LAR is technically advantageous.

Abstract Background The COVID‐19 outbreak made conventional medical care impossible, forcing changes in both healthcare providers and patients. In Japan, COVID‐19 infection began spreading in earnest in 2020 and exploded in 2021. There was concern that the medical impact of COVID‐19 in 2021 would differ from that in 2020. We aimed to clarify the impact of COVID‐19 on mortality and anastomotic leakage in laparoscopic surgery for gastric cancer and rectal cancer in Japan using the National Clinical Database (NCD). Methods We collected data from patients who underwent laparoscopic distal gastrectomy (LDG) and laparoscopic low anterior resection (LLAR) from January 2018 to December 2021 from the NCD, a web‐based surgical registration system in Japan. The number of surgical cases, monthly incidence of mortality and morbidity (anastomotic leakage), standardized mortality ratio (SMR), and standardized morbidity‐leakage ratio (SMLR [ratio of observed patients to expected patients calculated using the risk calculator established in the NCD]) were evaluated. Results The numbers of LDG and LLAR cases continued to decline in the first year of the pandemic in 2020 and were as low in 2021 as in 2020. Although the numbers of robot‐assisted LDG and LLAR cases increased, the growth rate was lower than the rate of increase prior to the pandemic. Mortality and anastomotic leakage, two of the most important complications, as assessed by SMR and SMLR, did not worsen during the pandemic in comparison to the pre‐pandemic period. Conclusions Laparoscopic surgeries were performed safely in Japan and were not affected by the COVID‐19 pandemic.

Background/Objective: Normal knee kinematics during flexion and extension activities over the whole range of motion remains unknown. This study aimed to clarify in vivo kinematics during knee flexion and extension activities of normal knees by comparing continuous flexion and extension activities up to a high flexion angle. Methods: Twenty knees of 10 Japanese volunteers were enrolled in this study. Each volunteer performed a continuous squatting motion under fluoroscopy, and a two- or three-dimensional registration technique was used. Rotation and anteroposterior translation of the medial and lateral sides of the femur relative to the tibia at each flexion angle were evaluated. Results: Femoral external rotation was significantly smaller from 10° to 40° flexion during extension activities than during flexion activities. However, the femoral external rotation was larger from 120° to 130° flexion during extension activities than during flexion activities. From 10° to 60° of flexion, the medial side was significantly more posteriorly located during extension activities than during flexion activities. Furthermore, the lateral side was significantly more posteriorly located at 130° of flexion during extension activities than during flexion activities. Conclusion: In vivo kinematics of normal knees during extension activities differ from those during flexion activities in early and high flexion.

The use of allergen immunotherapy (AIT) in Brazil has specific regional conditions owing to the pattern of allergen sensitization, as well as to genetic, socioeconomic, and cultural characteristics. This review article aims to discuss the clinical practice of AIT by the subcutaneous or sublingual route in Brazil, addressing the possibilities of transition between these forms of administration. A systematic review using the PubMed and Cochrane databases was performed, and the websites of major allergy and immunology organizations were consulted. Knowledge of the mechanism of action of subcutaneous immunotherapy and sublingual immunotherapy, together with Brazilian real-life experience, allowed us to establish recommendations regarding switching routes of AIT administration in selected cases. Careful analysis of each clinical situation is necessary to perform the transition between subcutaneous and sublingual allergen immunotherapy.

Current treatments of eosinophilic chronic rhinosinusitis (ECRS) involve corticosteroids with various adverse effects and costly therapies such as dupilumab, highlighting the need for improved treatments. However, because of the lack of a proper mouse ECRS model that recapitulates human ECRS, molecular mechanisms underlying this disease are incompletely understood. ECRS is often associated with aspirin-induced asthma, suggesting that dysregulation of lipid mediators in the nasal mucosa may underlie ECRS pathology. We herein found that the expression of microsomal PGE synthase-1 (encoded by PTGES) was significantly lower in the nasal mucosa of ECRS patients than that of non-ECRS subjects. Histological, transcriptional, and lipidomics analyses of Ptges-deficient mice revealed that defective PGE2 biosynthesis facilitated eosinophil recruitment into the nasal mucosa, elevated expression of type-2 cytokines and chemokines, and increased pro-allergic and decreased anti-allergic lipid mediators following challenges with Aspergillus protease and ovalbumin. A nasal spray containing agonists for the PGE2 receptor EP2 or EP4, including omidenepag isopropyl that has been clinically used for treatment of glaucoma, markedly reduced intranasal eosinophil infiltration in Ptges-deficient mice. These results suggest that the present model using Ptges-deficient mice is more relevant to human ECRS than are previously reported models and that eosinophilic inflammation in the nasal mucosa can be efficiently blocked by activation of the PGE2-EP2 pathway. Furthermore, our findings suggest that drug repositioning of omidenepag isopropyl may be useful for treatment of patients with ECRS.

Background: The mechanisms underlying non-alcoholic fatty liver disease (NAFLD) are not fully understood, but the gut microbiota is deeply involved. Because the Japanese traditional medicine bofutsushosan (BTS; Fangfengtongshengsan in Chinese) is known to improve obesity-induced liver injury and increase gut Akkermansia muciniphila, we evaluated its effects in a mouse model of diabetes-induced nonalcoholic steatohepatitis (NASH). Methods: Two-day-old male C57BL/6J mice were injected subcutaneously with streptozotocin and fed a high-fat diet (HFD) from 4 weeks. Between 5 and 8 weeks, HFD was supplemented with 5% BTS (BTS) or not supplemented (CONT), and plasma, liver, and stool samples were collected and analyzed. Results: The NAFLD activity score (NAS), which was consistent with early steatohepatitis in CONT mice, was significantly lower in BTS mice (P = 0.018). Improvement of steatosis contributed most to decreasing NAS. Relative abundances of probiotic Akkermansia muciniphila and Bifidobacterium pseudolongum were significantly higher in BTS mice (both P < 0.05). Positive correlations were observed among NAS, steatosis, ballooning, and body weight change. Liver macrophage markers correlated with some microbes in BTS mice. Conclusions: BTS administration suppressed liver steatosis and improved the gut microbiome, which correlated with some liver factors. BTS may be a promising treatment for NAFLD by maintaining the gut–liver axis.

Introduction: The combination of a giant omphalocele (GO) and congenital diaphragmatic hernia (CDH) is extremely rare and results in high mortality and morbidity rates in neonates. The most difficult period for survival is the immediate postnatal period, with approximately one-third of newborns dying within the first 48 h after birth. Case presentation: We present the case of a newborn girl with a GO and congenital left-sided Bochdalek hernia who survived beyond the neonatal period and underwent radical surgery. The female neonate, weighing 2946 g, was delivered by scheduled Cesarean section at 37 weeks gestation. She had a left-sided Bochdalek CDH containing a small portion of the small bowel and a GO containing a large portion of the liver. There were no other associated malformations, and the pulmonary hypoplasia and pulmonary hypertension in the neonatal period were not fatal. We performed an operation to repair the diaphragmatic hernia, initially approaching it from her abdominal wall defect. We performed multiple operations to close the abdominal wall. Initially, during the neonatal period, we closed it with a skin layer; however, poor weight gain occurred afterward. Considering gastroesophageal reflux as a complication, we performed mesh-assisted abdominal wall closure and fundoplication at 10 months of age, successfully resolving the underlying disease and complications. Conclusion: Repair of the CDH from the abdominal wall defect provided good visual field and safer primary direct closure. Without using artificial materials in the CDH until closure of the GO avoided infection and resulted in a favorable outcome in this case.