Background: Radical hysterectomy (RH) is a type of radical surgery for cervical cancer. Urinary dysfunction due to RH worsens postoperative quality of life of patients with cervical cancer. Nerve-sparing RH (NSRH) technique has been used as an effective means to conserve urinary function. However, few reports have examine long-term outcomes after NSRH. This study describes the details and long-term outcomes of our nerve-sparing technique. Methods: Sixty-one patients underwent radical hysterectomy in a 5-year period during which nerve-sparing technique was introduced; of these, 31 patients underwent NSRH and 30 underwent conventional RH. We retrospectively examined their medical records and compared postoperative urinary function and treatment outcomes between these two groups. Results: The median time required for urinary residual volume to fall to ≤50 mL after removal of the urinary catheter was 6 days (range, 2-20 days) in the NSRH group and 13.5 days (range, 3-46 days) in the RH group. The results were significantly better in the NSRH group (p < 0.05). The mean follow-up period was 2456.3 days (range, 48-4,213 days). Analysis of curability revealed no significant difference between the two groups in local recurrence or long-term survival rates. The 5-year survival rate was 0.861 in the NSRH group and 0.782 in the RH group; the 10-year survival rate was 0.861 in the NSRH group and 0.679 in the RH group. Conclusions: NSRH significantly improved postoperative urinary function without worsening local recurrence rates or long-term outcomes.

Purpose: To evaluate visual outcome and patient satisfaction following Lentis Comfort intraocular lens (IOL) implantation. Method: This retrospective case series examined 68 eyes of 41 patients (mean age 72.0 ± 8.1 years) who underwent Lentis Comfort (LS-313 MF15, Oculentis GmbH, Berlin, Germany; Santen, Osaka, Japan) implantations. Patients were evaluated for visual acuity (VA) at several distances (0.3, 0.5 and 5 meters), refractive error, defocus curve and contrast sensitivity, in addition to answering a questionnaire on photic phenomena, visual discomfort and patient satisfaction. Results: Uncorrected visual acuity was 0.05 ± 0.13 (logMAR) for distance, 0.23 ± 0.17 (logMAR) for intermediate, and 0.52 ± 0.20 (logMAR) for near. Defocus curve showed the binocular visual acuity attained was almost 20/20 within the range of +0.5 D to −1.5 D. Contrast sensitivity was within the normal range. The Lentis Comfort IOL tolerated astigmatism to some extent. Patient age could potentially be related to uncorrected visual acuity. Questionnaire results showed almost all patients were satisfied with Lentis Comfort IOL implantation. Conclusion: Lentis Comfort IOLs provided better visual function at far and intermediate distances.

Background: Ventilator weaning protocols are commonly implemented for patients receiving mechanical ventilation. However, despite such protocols, the rate of extubation failure remains high. This study analyzed the usefulness and accuracy of machine learning in predicting extubation success. Methods: We retrospectively evaluated data from patients who underwent intubation for respiratory failure and received mechanical ventilation in an intensive care unit (ICU). Information on 57 features, including patient demographics, vital signs, laboratory data, and ventilator data, were extracted. Extubation failure was defined as re-intubation within 72 hours of extubation. For supervised learning, data were labeled as intubation-required or not. We used three learning algorithms (Random Forest, XGBoost, and LightGBM) to predict successful extubation. We also analyzed important features and evaluated the area under curve (AUC) and prediction metrics. Results: Overall, 13 of the 117 included patients required re-intubation. LightGBM had the highest AUC (0.950), followed by XGBoost (0.946) and Random Forest (0.930). The accuracy, precision, and recall performance were 0.897, 0.910, and 0.909 for Random Forest; 0.910, 0.912, and 0.931 for XGBoost; and 0.927, 0.915, and 0.960 for LightGBM, respectively. The most important feature was duration of mechanical ventilation, followed by fraction of inspired oxygen, positive end-expiratory pressure, maximum and mean airway pressures, and Glasgow Coma Scale. Conclusions: Machine learning predicted successful extubation of ICU patients on mechanical ventilation. LightGBM had the best overall performance. Duration of mechanical ventilation was the most important feature in all models.

Background: The incidence and risk factors of postoperative nausea and vomiting (PONV) and early PONV (ePONV) were evaluated in patients who underwent breast surgery with volatile anesthesia. Methods: In this retrospective study, multivariate logistic regression was used to determine incidence and identify risk factors for PONV. Results: Among 928 patients, 166 (18%) and 220 (24%) had ePONV and PONV, respectively. In multivariate analysis, anesthesia duration and use of desflurane were independent risk factors for ePONV. For PONV, anesthesia duration and Apfel score were independent risk factors. Conclusions: Our results indicate that desflurane was the main cause of ePONV. However, during the delayed phase, a higher Apfel score was the strongest predictor. In the early and delayed phases, long anesthesia duration was associated with high risk of PONV. Thus, prolonged anesthesia and desflurane use should be avoided for patients at high risk of PONV, particularly those with high Apfel scores.

Background: Various optimal medical therapies have been established to treat heart failure (HF) with reduced ejection fraction (HFrEF). Both HFrEF and HF with preserved ejection fraction (HFpEF) are associated with poor outcomes. We investigated the effect of topiroxostat, an oral xanthine oxidoreductase inhibitor, for HFpEF patients with hyperuricemia or gout. Methods: In this nonrandomized, open-label, single-arm trial, we administered topiroxostat 40-160 mg/day to HFpEF patients with hyperuricemia or gout to achieve a target uric acid level of 6.0 mg/dL. The primary outcome was rate of change in log-transformed brain natriuretic peptide (BNP) level from baseline to 24 weeks after topiroxostat treatment. The secondary outcomes included amount of change in BNP level, uric acid evaluation values, and oxidative stress marker levels after 24 weeks of topiroxostat treatment. Thirty-six patients were enrolled; three were excluded before study initiation. Results: Change in log-transformed BNP level was -3.4 ± 8.9% (p = 0.043) after 24 weeks of topiroxostat treatment. The rate of change for the decrease in BNP level was -18.0 (-57.7, 4.0 pg/mL; p = 0.041). Levels of uric acid and 8-hydroxy-2'-deoxyguanosine/creatinine, an oxidative stress marker, also significantly decreased (-2.8 ± 1.6 mg/dL, p < 0.001, and -2.3 ± 3.7 ng/mgCr, p = 0.009, respectively). Conclusions: BNP level was significantly lower in HFpEF patients with hyperuricemia or gout after topiroxostat administration; however, the rate of decrease was low. Further trials are needed to confirm our findings.

Background: Because development of acute coronary syndrome (ACS) worsens the prognosis of patients with coronary artery disease, preventing recurrent ACS is crucial. However, the degree to which secondary prevention treatment goals are achieved in patients with recurrent ACS is unknown. Methods: 214 consecutive ACS patients were classified as having First ACS (n=182) or Recurrent ACS (n=32), and the clinical characteristics of these groups were compared. Fifteen patients died or developed cardiovascular (CV) events during hospitalization, and the remaining 199 patients were followed from the date of hospital discharge to evaluate subsequent CV events. Results: Patients in the Recurrent ACS group were older than those in the First ACS group (76.8±10.8 years vs 68.8±13.4 years, p=0.002) and had a higher rate of diabetes mellitus (DM) (65.6% vs 36.8%, p=0.003). The rate of achieving a low-density lipoprotein cholesterol (LDL-C) level of <70 mg/dL in the Recurrent ACS group was only 28.1%, even though 68.8% of these patients were taking statins. An HbA1c level of <7.0% was achieved in 66.7% of patients with recurrent ACS who had been diagnosed with DM. Overall, 12.5% of patients with recurrent ACS had received optimal treatment for secondary prevention. CV events after hospital discharge were noted in 37.9% of the Recurrent ACS group and 21.2% of the First ACS group (log-rank test: p=0.004). However, recurrent ACS was not an independent risk factor for CV events (adjusted hazard ratio: 2.09, 95% confidence interval: 0.95 to 4.63, p=0.068). Conclusion: Optimal treatment for secondary prevention was not achieved in some patients with recurrent ACS, and achievement of the guideline-recommended LDL-C goal for secondary prevention was especially low in this population.

Background: Gastrointestinal muscular sampling is useful in the histological assessment of functional gastrointestinal disorders. We devised a new sampling method to obtain a large volume of muscle tissues and then investigated the feasibility and safety of endoscopic muscular resection with a ligation device in an in vivo porcine model. Methods: After establishing a submucosal tunnel, a rubber band was placed on the muscle tissue by sucking the exposed muscle layer. Thereafter, the established pseudopolyp was removed using an electrocautery snare, and the entry site of the submucosal tunnel was closed endoscopically. This procedure was performed at three sites in the esophagus and stomach of two pigs. The technical success, histology, and survival rate on postoperative day 7 were examined postoperatively. Results: We successfully completed the mentioned procedure in 11 of the 12 sites (92%), without the occurrence of severe adverse events. The median diameters of obtained tissues from the esophagus and stomach, respectively, were 5 mm and 10 mm. Histologically, both the inner and outer muscle layers were included in all specimens. The postprocedural course was found uneventful in both pigs during the observatory period. Conclusions: Endoscopic muscular resection using a ligation device enabled us to obtain large and thick muscle tissue samples. This approach may facilitate more precise histological assessments of functional gastrointestinal disorders.

Background: A retrospective study of the real-world use of neoadjuvant endocrine therapy (NET) is important for standardizing the role of NET in breast cancer care. Methods: In a consecutive series of women with operable breast cancer who received NET for ≥28 days, associations of NET objectives, NET outcomes, adjuvant chemotherapy use after NET, and survival with clinicopathological factors were examined. Results: NET objectives were reduction in surgical extent in 49 patients, avoidance of surgery in 31, and treatment until scheduled surgery in 8. The mean duration of NET was 349.5 (range, 34-1,923), 869.8 (range, 36-4,859), and 55.8 (range, 39-113) days, respectively, in these cohorts (success rate: 79.6%, 64.5%, and 100%, respectively), and the differences were significant. Among patients in the former two cohorts, progression-free survival was significantly better in patients with stage 0 or I disease, ductal carcinoma in situ or invasive ductal carcinoma, ≥71% estrogen receptor (ER) positivity, and the surgical extent reduction cohort than the other counterparts. Postoperative chemotherapy use was significantly associated with lymph node metastasis, a high Ki67 labeling index, lymphovascular invasion, and a high preoperative endocrine prognostic index at the time of surgery after NET. Better recurrence-free survival after surgery was significantly associated with high ER expression after NET or high progesterone receptor expression before or after NET. Conclusions: NET can help reduce surgical extent or avoid surgery in women with early breast cancer, ductal carcinoma, or high ER expression. NET may also aid in decisions related to postoperative systemic therapy to improve survival.

Background: Peritonitis is one of the most common complications in patients undergoing peritoneal dialysis, (PD) but it is difficult to predict or prevent. In this study, we analyzed the risk of endogenous peritonitis in patients receiving PD. Methods: We included all patients who underwent PD at our hospital from April 2015 to March 2020. There were 22 cases of peritonitis, including 18 cases of endogenous peritonitis without evidence of exit-site infection or technical failure. We evaluated older age, female sex, obesity, diabetes, diverticulosis, and constipation as potential important risk factors for endogenous peritonitis and included these as confounding factors, along with a current or previous history of smoking, in univariate logistic regression models. Results: A previous or current history of smoking (p = 0.0065) was the most significant risk factor for endogenous peritonitis in the univariate logistic regression model. In addition, smoking was the most significant independent risk factor for endogenous peritonitis (p = 0.0034) in multivariate logistic regression models. Diabetes was also significant in univariate and multivariate logistic regression analysis. Conclusions: Smoking is a significant independent risk factor for endogenous peritonitis in patients undergoing PD. Cessation of smoking may lower the risk of endogenous peritonitis in this patient group.

Background: An inter-arm difference in blood pressure (IADBP) is characteristic of acute aortic dissection (AAD), but the importance of which arm exhibits lower blood pressure (BP) and the mechanism underlying IADBP are not well understood. Methods: We identified consecutive patients with chest and/or back pain and suspected acute cardiovascular disease whose BP had been measured in both arms. We retrospectively compared the characteristics of such patients with AAD (n=93) to those without AAD (non-AAD group, n=122). Additionally, we separately compared patients with type A AAD (TAAD group, n=58) or type B AAD (TBAD group, n=35) to the non-AAD group. The characteristics analyzed were patient background and IADBP-related factors, including systolic BP (SBP) in the right arm (R) and left arm (L), and R-L or L-R as IADBP. Computed tomography (CT) findings of AD extending to the brachiocephalic artery (BCA) and/or left subclavian artery (LSCA) were examined in patients with an IADBP. Results: In a comparison of the TAAD group and non-AAD group, the prevalences of R <130 mm Hg (38% vs. 19%, p=0.009), L-R >15 mm Hg (19% vs. 8%, p=0.047), L-R >20 mm Hg (14% vs. 4%, p=0.029) were higher in the TAAD group. Multivariate analysis showed that L-R >15 mm Hg with R <130 mm Hg was independently associated with TAAD (OR 25.97, 95% CI 2.45-275.67, p=0.007). However, IADBP-related factors were not associated with TBAD. AAD patients with L-R >20 mm Hg all had TAAD, and all aortic dissection extended to the BCA just before the right common carotid artery on CT. Conclusions: IADBP was characterized by R<L with low R in TAAD but was not associated with TBAD.

Background: More than 30 years have passed since the Japanese government announced its International Student 100,000 Plan in 1983. Today, the number of international students in the country exceeds 300,000. This study examines the relationship between factors affecting the mental health of international students and their satisfaction with having studied abroad in Japan. Methods: An online-questionnaire was given to 82 former Japanese government scholarship students who studied in Japan in the 1980s. The survey consisted of items related to the basic personal attributes of the participants, their lives in Japan during their period of study (20 items), their satisfaction level at having studied in Japan (10 items), and their current happiness level (4 items). Results: A significant relationship was observed between the level of satisfaction at having studied in Japan and a number of the statements relating to respondents' lives in Japan as students, including: "I felt that the differences between Japan and my home country were interesting, and enjoyed these differences," and "Whenever I encountered a difficult situation, I attempted to find different approaches to deal with the problem." A similar relationship was also observed between these statements and subjective happiness. Conclusions: International students who were able to accept the differences and difficulties they confronted positively and respond to situations flexibly tended to report higher levels of satisfaction with their studies in Japan and higher levels of happiness, suggesting that individual psychological factors, such as situation perception and associated coping behaviors, have a defining impact on mental health.

Background: Modafinil improves wakefulness and attention, is approved in Japan for treatment of narcolepsy, and was reported to be effective for attention-deficit/hyperactivity disorder. However, it was reported to induce emotional instability, including mania, depression, and suicidal ideation. Such side effects may be related to changes in cognitive behavior caused by the effects of modafinil on emotional recognition. However, the effects of modafinil on the neural basis of emotional processing have not been fully verified. We used functional magnetic resonance imaging to investigate the effects of modafinil on the neural basis of auditory emotional processing. Methods: This study adopted a placebo-controlled within-subject crossover design. Data from 14 participants were analyzed. The effects of modafinil on cerebral activation and task performance during an emotional judgement task were analyzed. Results: Task accuracy decreased significantly and response time of emotional judgement was significantly delayed by modafinil, as compared with placebo. Right thalamic activation in auditory emotional processing was significantly less in the modafinil condition than in the placebo condition. In addition, reduction of right thalamic activation by modafinil was positively correlated with accuracy of emotional judgement. Conclusions: Our findings suggest that modafinil acts on the right thalamus and changes behavior and brain function associated with auditory emotional processing. These results indicate that modafinil might change emotional recognition by reducing emotional activation related to social communication.

Background: The benefit of chemotherapy for patients with metastatic colorectal cancer has not been established. Methods: We retrospectively evaluated the effectiveness of chemotherapy with capecitabine and bevacizumab for patients with a performance status (PS) of 3. Results: Seven patients were included; median age was 82 years (range, 65-91 years). Response was not ascertained; however, the disease control rate was 83.3%. Median PFS and OS were 10.0 and 25.8 months, respectively. Hand-foot syndrome was the most common toxicity observed (3 patients; 42.9%). Grade 3 toxicity was observed in 1 patient with proteinuria and 1 with hypertension. Conclusion: Chemotherapy using capecitabine and bevacizumab appeared to improve OFS and OS for patients with poor PS. However, care must be taken not to impose unnecessary burdens on patients with poor PS.

Ganglion cysts are common benign lesions in the hand and wrist. However, intratendinous ganglion cysts are uncommon. We present a case of intratendinous ganglion cyst in the extensor pollicis longus (EPL) tendon of the right hand of a 73-year-old woman. The subcutaneous mass moved in concert with the EPL tendon in her right thumb. Magnetic resonance imaging showed a space-occupying lesion in the EPL tendon. Biochemical and hemato-immunological examinations ruled out diabetes, rheumatoid arthritis, and other connective tissue diseases. She reported motion pain during thumb extension, for which she desired surgery. An intratendinous cyst was identified intraoperatively within the tendon substance of the EPL, in which a part of the cyst was herniated into a slit in the tendon substance, just distal to the extensor retinaculum, without notable proliferative synovial tissue. The EPL tendon was opened longitudinally, and a cystic lesion was enucleated. Pathological examination showed that the cyst wall consisted of fibrous tissue with degeneration and no epithelial lining. Postoperative recovery was uneventful. Six months after surgery, the patient had no residual pain and no cyst recurrence. The rarity of intratendinous ganglion cysts makes diagnosis and treatment challenging. Because intratendinous ganglion cysts and associated synovitis frequently weaken the structure of affected tendons, prompt diagnosis and surgical excision are necessary.

Decreased vision and cystoid macular edema (CME) developed in phakic eyes of a patient who underwent laser iridotomy after changing the glaucoma eye drops from carteolol 2% long-acting ophthalmic solution to omidenepag isopropyl 0.002%. CME completely disappeared at approximately 2 months after discontinuation of omidenepag isopropyl in conjunction with the use of bromfenac sodium 0.1%.

We describe the case of a primary open-angle glaucoma patient with re-elevated nocturnal sitting intraocular pressure (IOP) after restarting medical therapy due to a failing bleb. IOP was markedly higher than diurnal IOP during multiple-drug therapy in both eyes, but it did not increase in the left eye with a functional bleb without medical therapy after trabeculectomy with adjuvant mitomycin. However, nocturnal sitting IOP was re-elevated after restarting multiple-drug therapy due to a failing bleb, while diurnal IOP was maintained at a low level.