Adult spinal deformity (ASD) is common spinal disorder in the elderly. The feature of spinal alignment in ASD patients is loss of lumbar lordosis, which results in a forward leaning posture. Sagittal imbalance has been shown to correlate with poor health related QOL especially concerning upright standing and walking. Past studies have been conducted to understand ideal sagittal global alignment, and some formulas have been developed to calculate the ideal lumbar lordosis matching pelvic incidence, which assists in surgical planning when deciding the amount of correction. To evaluate the individual spinal deformity in the sagittal plane, understanding the presence of compensatory mechanisms is indispensable. The basic mechanisms of sagittal compensation are extension of the neighboring flexible spine or backward rotation of the pelvis to avoid anterior translation of the gravity line. Global evaluation of the entire spine and pelvis including compensatory mechanisms allows for better planning for surgical management of these patients. This paper provides an overview of the sagittal spinal parameters which concern the diagnosis and treatment of patients with ASD, and describes a therapeutic solution for future ASD care.

Hypertensive disorders of pregnancy, especially preeclampsia, can cause severe damage to both mothers and children. Although the cause and pathogenesis of this disease had remained unknown for many years, recent evidence revealed that failed placentation is the primary cause of preeclampsia, and statistics to predict the onset of disease have been developed. Low dose aspirin is expected to prevent the onset of this disease, and various antihypertensive drugs, which had been previously regarded as contraindicated during pregnancy, are just approved for use in Japan. In contrast, lifelong follow up of women who have experienced hypertensive disorders of pregnancy, especially in Japan, is not yet fully functional. This review focuses on current knowledge on the pathogenesis of hypertensive disorders of pregnancy and novelties regarding its prediction, prevention, and treatment, with a particular emphasis on the current situation in Japan.

Nephrotic syndrome (NS) in children responds well to steroid therapy, therefore kidney biopsy before treatment is often avoided. However, the indications for kidney biopsy in children with NS with microscopic hematuria are controversial. In the present study, the indications for pretreatment kidney biopsy at the onset of pediatric patients with NS with microscopic hematuria were evaluated. Clinicopathologic correlations were retrospectively examined from patients enrolled in a database from January 2005 to December 2018. Fifty-nine pediatric patients with NS were enrolled. Among them, 6 with hypocomplementemia, gross hematuria, or onset at less than 1 year of age were excluded. Of the 53 enrolled patients, 38 without hematuria were assigned to Group A, and 15 patients with microscopic hematuria comprised Group B. There was a significant difference in the renal biopsy rate between Group A (n = 19, 50%) and Group B (n = 13, 87%) (P = 0.01). Two patients in Group B avoided biopsy. Pathology results for patients in Group B included 4 patients with minimal change disease, 2 with focal segmental glomerulosclerosis, 6 with mesangial proliferative glomerulonephritis (non-IgA), and 1 with membranous lupus nephritis (LN). The first three are commonly found in pediatric patients with NS, and all are treated with steroid therapy. LN could be diagnosed by kidney biopsy at the time of steroid resistance. LN presenting with nephrotic syndrome is also treated with steroids. Thus, the treatment strategy would not have changed even if the kidney biopsy had been performed before treatment. These results suggest that renal biopsy is not always mandatory during the initial stage for pediatric patients with NS with microscopic hematuria.

Aims: The aim of the present study was to evaluate the effect of changing from a dipeptidyl peptidase (DPP)-4 inhibitor to oral semaglutide on glycemic control, as reflected by hemoglobin A1c (HbA1c), occasional plasma glucose (PG) and glycoalbumin (GA), and body weight (BW) in routine clinical practice.

Patients and Methods: A search of electronic medical records was performed for patients treated with a DPP4 inhibitor for diabetes mellitus and who were then changed to oral semaglutide because of relatively poor glycemic control from December 2021 to March 2022. A total of 19 patients met these inclusion criteria. Data for these patients were evaluated until the end of August 2022.

Results: HbA1c and occasional PG were significantly decreased compared to baseline (the time of changing treatment) at 4 months and at the final visit (a mean of about 6 months). GA was significantly decreased from baseline at 1 month, 4 months, and at the final visit. BW was also significantly decreased from baseline at 4 months and the final visit. There were no statistically significant changes in low-density lipoprotein cholesterol (LDL-C), triglyceride (TG) or estimated glomerular filtration rate (eGFR).

Conclusion: These results of the present study show that changing from a DPP4 inhibitor to oral semaglutide significantly improved glycemic control, as reflected by HbA1c, occasional PG and GA, and led to a significant reduction in BW after an observational period of over 4 months.

Clear diagnostic and treatment standards have not yet been established for pediatric obstructive sleep apnea (OSA), so a considerable number of patients, including those yet undiagnosed, may be left untreated in Japan. However, it is practically impossible to conduct overnight polysomnography (PSG) tests, which are considered useful for diagnosis, for all cases of suspected pediatric OSA because of insufficient manpower in pediatric medical care and detachment of electrodes due to frequent body movements. To clarify the usefulness of surgical treatment for pediatric OSA, a retrospective study was conducted using PSG parameters, including the apnea hypopnea index (AHI) on 32 patients.

Of 144 patients (93 boys, 51 girls, average age at first visit: 9.1 ± 2.9 years, 30 preschool children under seven years old) who were able to undergo PSG, 32 patients with pre- and post-surgery PSG data were included (18 boys, 14 girls, average age at first visit: 8.4 ± 2.4 years, eight preschool children under seven years old). Additionally, eight patients had a pre-treatment body mass index (BMI) of 25 or higher. Allergic diseases such as bronchial asthma and allergic rhinitis were the most common complications (18/32, 56.3%). Comparing post- and pre-surgical PSG parameters, significant decreases were observed for AHI, apnea index (AI), and oxygen desaturation index (ODI); significant increases were observed for stage REM and REM sleep time (p < 0.05).

Despite the limited number of cases, our data suggest that polysomnography is useful in determining the indication of surgical treatment and its efficacy in children with OSA.

Infants and young children are prone to hyperkalemia caused by decreased renal potassium excretion. However, there are limitations to the use of current hyperkalemia drugs in pediatric patients. To address this issue, we developed a young rat hyperkalemia model by the combined administration of potassium chloride (KCl) and amiloride (Ami) to test new drug candidates for young patients. We administered KCl (2, 3, 4.5, and 6 mEq/kg) and Ami (3 mg/kg) intraperitoneally to five-week-old male Wistar-Imamichi rats and placed them in metabolic cages. After 6 h, blood and urine samples were collected. The combined administration of KCl and Ami increased the serum-potassium concentration compared to the control (2 mEq/kg; 5.2 vs 4.5 mEq/L, P ＝ 0.039, 6 mEq/kg; 6.8 vs 4.1 mEq/L, P = 0.005, n = 5) in a dose-dependent manner. Next, the rats were orally administered furosemide (30 mg/kg, FURO), a known hyperkalemia treatment, or Compound 21 (C21) (10 and 30 mg/kg), an angiotensin II type 2 receptor agonist and candidate drug for hyperkalemia. FURO was administered as a single dose (after 1 h) or as repeated doses (after 1, 3, and 5 h). The serum-potassium concentration was significantly decreased by FURO (single dose; 5.9 vs 6.8 mEq/L, P = 0.017, n = 7, repeated doses; 5.6 vs 6.3 mEq/L, P = 0.021, n = 7). However, C21 did not decrease the serum-potassium concentration compared to the control (6.6 vs 6.8 vs 7.2 mEq/L, P = 0.07). Overall, this model can be used to evaluate the effects of candidate therapeutic drugs for hyperkalemia in school children caused by decreased urinary-potassium excretion.

Management of hyperpotassemia is important in a perioperative period. Decreased renal-potassium excretion is a major mechanism of hyperpotassemia. However, current therapeutics for renal hyperpotassemia are not specific to the target site. Thus, we develop an animal model of renal hyperpotassemia for use in evaluation of candidate drugs. Nine-week-old male Wistar-Imamichi rats were intubated after anesthesia and attached to a ventilator. Heart rate and arterial blood pressure were continuously measured. After continuous infusion (c.i.) of normal saline for 30 min amiloride was given bolus infusion (36 μg/kg) followed by c.i. of KCl (0.3, 0.6, 0.9 mmol/kg) and amiloride (10.8 μg/kg) for 75 min. Blood pH was measured before and after co-administration of KCl and amiloride. Serum potassium concentration and urinary potassium excretion were measured every 15 min by collecting arterial blood and urine via indwelling catheters. Changes in serum potassium concentration from a value immediately before the co-administration of KCl and amiloride were expressed as Δpotassium. An increase in the Δpotassium was dose-dependent and greater in the KCl 0.6 and KCl 0.9 compared with the control (P = 0.024, 0.0003, respectively). It was also greater in the KCl 0.6 and amiloride than KCl 0.6 (P = 0.016). The blood pH was not changed among the groups. Blood pressures and heart rates tended to decrease, and urine volume tended to increase in all groups. In conclusions, we developed a renal hyperpotassemia model in the general anesthetized rats with a stable pH which could minimize potassium fluctuations. This model can be applied for evaluation of the candidate drugs for renal hyperpotassemia.

Electroconvulsive therapy (ECT) leads to remarkable hemodynamic changes. Heart rate variability (HRV), which comprises high frequency (HF) or low frequency (LF), is an index of cardiac autonomic regulation. In the present study, we examined the effects of remifentanil on HRV changes during ECT. After obtaining approval from the ethics committee of Dokkyo Medical University Hospital, we randomly allocated 42 patients who were scheduled to undergo ECT with American Society of Anesthesiologists physical status I or II to group R (n = 21), which received remifentanil (1 μg/kg) as pretreatment, or group C (n = 21), which did not receive pretreatment. After the induction of general anesthesia, we recorded the LF/HF ratio and HF ratio every minute during ECT. Statistical analysis was performed using two-way analysis of variance. Immediately (T0) and 1 min (T1) after convulsion, heart rate, systolic and diastolic blood pressures were significantly lower in group R than in group C. The LF/HF ratio in group R was significantly lower than that in group C (group C: T0; 28.6 ± 24.3, T1; 20.1 ± 18.6, group R: T0; 16.1 ± 9.7, T1; 11.2 ± 9.9, p < 0.05). No significant difference was noted in the HF ratio between both groups. Pretreatment with remifentanil suppresses hemodynamic and cardiac autonomic activity changes during electroconvulsive therapy.

A patient for whom the diagnosis of a pancreatic metastasis from renal cell carcinoma was made with endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is presented. The patient was a 77-year-old man. Three years after resection of renal cell carcinoma (T_3bN₀M₁ Stage 4), a lung metastasis was found on computed tomography (CT) scan, and chemotherapy scheduled. Tests were positive for HBc antibodies on preoperative screening, and abdominal ultrasound showed a well-defined, hypoechoic mass in the head of the pancreas. EUS-FNA was performed for definitive diagnosis. The pathological results were consistent with metastasis to the pancreas from the previous renal cell carcinoma. In diagnosing a pancreatic metastasis from renal cell carcinoma, contrast-enhanced CT scan and angiography are useful to differentiate the lesion from pancreatic cancer, but contrast studies cannot always be performed because of renal dysfunction, contrast agent allergies, or other reasons. Even when contrast studies are performed, it is difficult to differentiate pancreatic metastases from renal cell carcinoma and pancreatic neuroendocrine tumors, and histological diagnosis is generally considered necessary.

Pulmonary sarcomatoid carcinoma accounts for 0.1%-0.5% of all lung cancers. It has an aggressive biological behavior and is often resistant to conventional chemotherapy and radiation therapy. An 84-year-old man presented with a painful mass in the left breast. Physical examination revealed two palpable subcutaneous nodules on the back. Computed tomography (CT) scan revealed a 4-cm mass in the upper lobe of the right lung and mediastinal lymphadenopathy. Positron emission tomography (PET) /CT scan revealed excessive FDG hyperaccumulation in the right pulmonary mass, left breast mass, subcutaneous nodules on the back, left second rib, and third thoracic vertebra. Histopathological examination of a needle biopsy specimen obtained from the breast mass revealed atypical spindle cell proliferation with numerous mitoses. Immunohistochemical examination revealed positive staining of the tumor cells for CAM 5.2, and the Ki-67 positive rate was 70%. The patient was diagnosed with non-small cell lung carcinoma containing a spindle-cell carcinoma component, cT4N2M1c, stage IVB. The PD-L1 (22C3) tumor proportion score was 90%. The patient received pembrolizumab 200 mg every three weeks with a partial response. He has continued to receive pembrolizumab for over one year. Further studies on a large number of patients are warranted to evaluate the efficacy of PD-1/PD-L1 inhibitor therapy for pulmonary sarcomatoid carcinoma.

Introduction: Generalized discoid lupus erythematosus (DLE) is a rare skin manifestation; however, about 15-28% of cases may develop into Systemic Lupus Erythematosus (SLE). Generalized DLE with SLE showed a poorer prognosis and required holistic therapy.

Case Report: A 20-year-old female complained of red rash on the skin, worsen with sun exposure in the past two years. She complained of joint pain, fever, decreased appetite, and fatigue, twenty months after the skin rash onset. Skin examination on the scalp, face, trunk, hands and feet showed erythematous to hypopigmentation patches, atrophic skin, and erosions covered with crusts. Laboratory investigations revealed anemia, high titers of ANA, and anti-dsDNA. Histopathological results were consistent with lupus erythematosus. Consultation with an ophthalmologist showed no contraindications to hydroxychloroquine. She was diagnosed with generalized DLE with moderate SLE and showed an excellent response to hydroxychloroquine, methotrexate, both systemic and topical corticosteroids, and sunscreen.

Discussion: Generalized cutaneous lupus can be treated with a topical therapy such as corticosteroid, sunscreen, and systemic therapy such as hydroxychloroquine and corticosteroid. Methotrexate, as a steroid-sparing agent, has a role in treating moderate to severe SLE and lupus arthritis.

Conclusion: Early recognition of SLE in a patient with cutaneous lupus and adequate therapy in generalized DLE is essential. Combination therapy showed better efficacy than monotherapy in generalized cutaneous lupus accompanied by SLE.