Background: This study assessed the effectiveness of the dural puncture epidural (DPE) technique in managing breakthrough pain in parous women receiving labor analgesia during induced labor. Methods: This single-center retrospective cohort study included term pregnant women with singleton pregnancies who received treatment for breakthrough pain during labor. All participants underwent induced labor, and some parous women among them underwent DPE. The DPE technique consisted of placing an epidural catheter after dural puncture with a 27-gauge spinal needle. Eligible women were allocated into a DPE group and conventional epidural (CE) anesthesia group. Pain was assessed with a numerical rating scale (NRS), and a patient-controlled epidural analgesia (PCEA) bolus was administered when the NRS score was ≥3. Breakthrough pain was defined as an NRS score ≥3 during PCEA management. The primary outcome was the efficacy of rescue interventions in managing breakthrough pain, as determined by a reduction in pain intensity to an NRS score <3 before birth. Results: Among the 55 parous women who received labor analgesia, 44 required additional rescue administration for breakthrough pain. Of the remaining women, 23 received DPE and 19 received CE anesthesia. The DPE group experienced significantly more effective relief of breakthrough pain before birth than did the CE group (DPE: 100%; CE: 68.4%; p=0.005). Conclusion: In parous women, DPE anesthesia was more effective than CE anesthesia in providing analgesia for breakthrough pain immediately before delivery during induced labor.

Background: Postoperative bleeding is a potentially life-threatening complication following thyroidectomy, but the risk factors and timing remain insufficiently understood. The bleeding rate for endoscopic surgery, specifically video-assisted neck surgery (VANS), also remains unclear in Japan. Methods: We conducted a retrospective case-control study of postoperative bleeding requiring readmission to the operating room. Results: The overall postoperative bleeding rate was 1.85%. Multivariate analysis revealed that postoperative bleeding was independently associated with antithrombotic therapy (odds ratio 2.95; 95% confidence interval 1.15-7.59) and dialysis (odds ratio 6.53; 95% confidence interval 1.75-24.2). Among patients with postoperative bleeding, the complication developed within 6 h in 56.1% and within 24 h in 93.0%. The postoperative bleeding rate in endoscopic surgery was 1.6%. The most common site of bleeding was around the thyroid in conventional surgery and around the flap in endoscopic surgery. Conclusions: Post-thyroidectomy bleeding is associated with antithrombotic therapy or dialysis. While the bleeding rate in endoscopic surgery is similar to that in conventional surgery, the bleeding site differs.

Background: The increasing prevalence of chronic kidney disease (CKD) requires effective preventive measures, particularly due to an aging population. This study aimed to assess the effectiveness of home visit rehabilitation in preventing renal function decline among patients with CKD. Method: In this retrospective study, patients with non-dialysis CKD undergoing home visit rehabilitation were compared with those receiving outpatient care at the Nippon Medical School Hospital between August 2017 and August 2023. Patients' backgrounds were matched using propensity scores derived from a logistic regression model. The primary endpoint was the annual change in the estimated glomerular filtration rate (eGFR), and the secondary endpoint was the annual change in blood parameters (Δblood urea nitrogen, Δcreatinine, Δtotal protein, Δalbumin, ΔC-reactive protein, Δhemoglobin, and Δhematocrit). Furthermore, the incidence of clinical outcomes, including mortality, hospitalization rate, and dialysis initiation rate, were analyzed within the additional 1-year observation period. Results: Overall, 128 patients (64 matched pairs) were analyzed. After a mean follow-up period of 12.7 ± 4.6 months, there was no significant difference in the eGFR between both groups (40.1 ± 13.7 vs. 37.8 ± 13.8 mL/min/1.73 m², p = 0.36), but the annual decline in eGFR (%/year) was significantly lower in the rehabilitation group (−1.1 ± 29.8% vs. −11.8 ± 27.7%/year, p = 0.037). The annual change in the level of each blood test parameter and clinical outcomes were not significantly different between the two groups. Conclusion: Home-based rehabilitation interventions may mitigate the progression of renal impairment in patients with CKD.

Background: We aimed to investigate the contribution of the palatopharyngeal muscle (PP) as a speech muscle in adjusting the velar position. Methods: X-ray kinematic analysis of the position of the palatopharyngeal arch and an electromyographic study of the PP during speech were performed in two healthy volunteers. Results: X-ray kinematic analysis revealed that the palatopharyngeal arch was positioned lower during the production of the low-back vowel /a/. However, no significant differences were observed between the vowels included in the nasal sounds during nasal sound productions. The electromyographic study showed higher PP activity during nasal sound productions. However, no significant differences were observed in muscle activity during the productions of five vowels or the same vowels included in the nasal sounds. During the production of two consecutive phonemes involving voiceless bilabial plosive consonants and nasal sounds, the PP activity demonstrated synchronous coordination with the levator veli palatini muscle activity. This activity was higher during the production of the low-back vowel /a/ included in the voiceless bilabial plosive consonant. It was also higher during the production of voiceless bilabial plosive sounds than during the production of voiced bilabial plosive sounds. Conclusions: When the distance between the origin and arrest of the PP is achieved through the velar elevation, the tonic condition and muscle strength of the PP are enhanced. When the scaffold below the PP is stabilized by the contractions of the glossopharyngeal part of the superior pharyngeal constrictor muscle during the production of the low-back vowel, the PP likely contributes to regulation of the velar position.

Background: The coronavirus disease 2019 (COVID-19) pandemic has forced people to make major life changes, and there is concern that depressive tendencies have increased in pregnant women during the pandemic. This study used the Edinburgh Postnatal Depression Scale (EPDS), administered in the second trimester, to investigate the effect of COVID-19 on the mental health of Japanese women during pregnancy and to provide early intervention. Methods: The study included 1,320 pregnant women (663 pre-COVID-19 and 657 during COVID-19) with similar background characteristics and compared the results for the COVID-19 period (September 2020-August 2021) and control period (September 2018-August 2019). Women treated for psychiatric disorders were excluded. The EPDS cutoff score was 13. Results: The median EPDS scores were 3 (1-6) points during the control period and 3 (1-5) points during the pandemic (p = 0.166) for the control and pandemic periods. Fourteen patients (2.1%) during the control period and 20 (3.0%) during the pandemic scored ≥13 points; however, the difference was not significant (odds ratio, 1.455; 95% confidence interval: 0.692-3.143). Conclusions: COVID-19 did not change mid-pregnancy EPDS scores at a single Japanese center.

Background: Spontaneous isolated visceral artery dissection (SIVAD) is rare. Recently, appropriate treatment strategies for symptomatic SIVAD have been proposed. We aimed to determine the management of asymptomatic spontaneous isolated superior mesenteric artery dissection (ASISMAD), which is relatively frequently encountered in SIVAD. Methods: We retrospectively reviewed abdominal contrast-enhanced computed-tomography (CE-CT) scans from January 2015 to December 2020 in our institution and identified 24 patients with ASISMAD. Patient characteristics, vascular risk factors, complications, morphology features on CE-CT images, changes in abdominal CE-CT, and treatments outcomes were analyzed. Results: All patients were male. The mean age of the patients was 66.0 ± 8.9 (standard deviation) years, and the follow-up period was 24.8 ± 28.7 months. The CE-CT images revealed that 1 patient had periarterial fat stranding, 15 patients had aneurysmal dilatation, and 7 patients had branch vessel involvement. The mean length of the dissection was 19.9 ± 13.5 mm. The mean distance from the orifice of the superior mesenteric artery to the dissection origin point was 14.9 ± 8.8 mm. The mean branching angle was 54.8°± 19.7°. None of the patients had dissection-related abdominal symptoms or complications. Follow-up CE-CT scans showed progression of the dissection in 2 (8.3%), improvement in 2 (8.3%), stable dissection in 17 (70.9%), and complete remodeling in 3 (12.5%). Conclusions: Patients with ASISMAD do not require hospitalization because the pathology does not usually progress to visceral ischemia. Nevertheless, follow-up CE-CT is required because of progression of the dissection in rare cases.

Background: Several effective treatment modalities against metastatic castration-resistant prostate cancer (mCRPC) are available; however, an unmet clinical need persists for mCRPC treatment because resistance to these therapies is inevitable. This study aimed to evaluate the status of comprehensive genomic profiling (CGP) and its impact on subsequent treatments for patients with mCRPC at our hospital. Methods: Between December 2020 and August 2023, we assessed 41 patients with mCRPC who underwent CGP testing at the Nippon Medical School Hospital. The testing comprised FoundationOne^® CDx for 30 patients and FoundationOne^® Liquid CDx for 11 patients, following the procedures outlined by the Japanese Urological Association. Results: CGP testing was successfully conducted in 40 out of 41 patients (97.6%), which resulted in the identification of 140 actionable genomic alterations. The most common alteration was TP53 in 12 patients (30.0%). Twenty-three patients (57.5%) with druggable gene alterations were identified; 21 were recommended for clinical trials, four for patient-proposed healthcare services, and six for insurance-covered drugs. Consequently, genotype-matched therapy with insurance-covered drugs was administered to five patients (12.5%) with a BRCA2 mutation. Notably, none of the patients underwent clinical or prospective trials based on patient-suggested medical services. Conclusions: Our results offer insights into the real-world application of CGP testing for patients with mCRPC at a cooperative hospital for cancer genomic medicine in Japan. Thus, urologists require a comprehensive understanding of the current status of CGP testing to enhance mCRPC management.

Background: Anatomical landmarks and range-of-motion (ROM) techniques are commonly used to rotationally align the tibial component in total knee arthroplasty (TKA). This study investigated; 1) the difference in tibial rotational alignment between the ROM technique and Akagi's line, 2) the influence of preoperative deformity and intraoperative gaps on this difference, and 3) intraoperative tibial rotational kinematics associated with these 2 techniques. Methods: Patients who underwent cruciate-substituting (CS) TKA (Evolution, Microport Orthopedics) for knee osteoarthritis were enrolled. Intraoperatively, the rotational alignment of the tibial component was determined with the ROM technique and recorded. The difference from the value determined using Akagi's line was evaluated. Correlations among preoperative coronal deformity, postoperative coronal alignment, and intraoperative gaps between the femur and tibia were evaluated. Differences in knee kinematics (rotational movement of the tibia against the femur) between the 2 techniques were compared. Results: This study included 34 knees from 34 patients. The rotational alignment of the tibial component using the ROM technique was 2.5±6.4° externally rotated in relation to that determined using Akagi's line (p=0.029), which was increased in knees with a smaller preoperative medial proximal tibial angle (r=0.45). Tibial rotational kinematics did not significantly differ between the 2 techniques. Conclusions: The ROM technique and Akagi's line yielded significantly different values for the rotational alignment of the tibial component. Orthopedic surgeons using Evolution (CS) should be reminded that in knees with proximal tibial varus deformity, the ROM technique will result in external rotation of the tibial component in relation to Akagi's line.

Background: The decreasing trend in the number of young suicides in Japan changed to a flat/increasing trend in 2017. To identify how this change was reflected in young suicide attempters, we investigated changes in the characteristics of young suicide attempters admitted to our emergency room. Methods: The subjects were suicide attempters younger than 30 years admitted to the Critical Care Medical Center of Nippon Medical School Hospital between January 1, 2010, and December 31, 2021. The means of suicide attempt, sociodemographic data, psychiatric diagnoses, and causes and motives of suicide attempts were retrospectively examined from medical records. We compared post-2017 to pre-2017 suicide attempts and performed a statistical analysis. Results: The proportion of suicide attempters younger than 30 years was 27.9% (143 of 513) before 2017 and 38.0% (132 of 347) after 2017, a significant increase. From 2017 to 2021, there was a significant increase in the number of female suicide attempters younger than 30 years and in the percentage of drug overdoses. Conclusions: The proportion of suicide attempters younger than 30 years was significantly higher after the start of 2017 than before 2017, possibly because of an increase in drug overdoses.

Invasive neonatal infection with Group B Streptococcus (GBS) is a disease of concern that can lead to neurological sequelae. Guidelines for preventing mother-to-child transmission have been introduced to reduce the incidence of early-onset infection, but guidelines for controlling the late-onset form are lacking. Recently, the trans-breastfeeding route of transmission has been highlighted as an example of late-onset infection, but no consensus on how to manage such infections has been reached. In this report, we describe a case of late-onset bacteremia/meningitis in a neonate suspected to have been infected with GBS via breastfeeding. A vaginal culture test of the mother at 35 weeks' gestation was negative for GBS. Since she had symptoms of mastitis, breast milk and nipple cultures were also tested and found to be positive for the strain of GBS identified in the neonate on genetic analysis. Diagnosis of trans-mammary GBS infection is challenging because breastfeeding-related events are difficult to identify. In our case, the diagnosis was based on the mother's history of mastitis, and the patient was treated without escalation to sequelae. When a neonate develops a fever, physicians should consider GBS infection and examine the mother's medical history to facilitate accurate diagnosis, especially if the history includes mastitis. A breast milk culture should be performed if the mother has mastitis, especially in cases of infection in preterm infants and in recurrent cases.

Pyogenic sacroiliitis is rare and difficult to diagnose because of its deep location and the absence of definitive clinical signs. Delayed diagnosis can result in complications such as abscess or sequestration formation, prolonged sepsis, and chronic joint deformity. MRI is a well-known, noninvasive imaging technique with a high sensitivity and specificity for osteomyelitis diagnosis. Here, we present the MRI findings for pyogenic sacroiliitis, 3 days after symptom onset, in an 11-year-old girl and confirm its value in early diagnosis of pediatric pyogenic sacroiliitis.

Rosai-Dorfman disease (RDD), which was first reported by Rosai and Dorfman in 1969, is a rare, benign, non-neoplastic proliferation of histiocytes, characterized by painless lymphadenopathy and fever. Lymphadenopathy occurs most commonly in the neck, but also appears in non-cervical lymph nodes or as extranodal lesions. In this case, biopsy of an atypical subcutaneous buccal mass, which was difficult to diagnose preoperatively, led to a diagnosis of RDD. In addition, although lesions were also confirmed in the maxilla, none of the lesions were in lymph nodes; therefore, we ultimately diagnosed the patient with extranodal RDD (ENRDD). Compared with classical RDD, characterized by painless lymphadenopathy and fever, ENRDD is observed only in soft tissue and bone, and occurs mostly frequently among older adults. Cases presenting with lymph node or vital organ lesions also present with systemic symptoms, usually with a progressive and sometimes fatal course. However, RDD localized in soft tissue and bone has a favorable prognosis, and follow-up alone is considered sufficient. Although this case featured epidemiological characteristics of ENRDD, and as there are no fixed therapeutic guidelines, the recommendation is that treatment be considered on a case-by-case basis according to the site and symptoms. There are few reports of ENRDD; therefore, we aim to contribute the details of an additional case to the literature.

The artery of Percheron (AOP), a common anatomic vascular variation of the P1 segment of the posterior cerebral artery, provides arterial blood supply to the paramedian thalami and rostral midbrain. Occlusion of the AOP can lead to infarction of the bilateral paramedian thalamus, with or without midbrain involvement, but is rare in children. Here, we describe a case involving a 14-year-old girl with sudden onset of disturbance of consciousness, hypersomnia, and global aphasia. Brain magnetic resonance imaging showed symmetric bilateral paramedian thalamic infarcts. Left-sided AOP infarction was diagnosed by brain angiography.

Ischemic colitis is a common disease with a good prognosis; however, complications can occur in the presence of a serious underlying disease. Herein, we present a case report in which characteristic findings on lower gastrointestinal endoscopy led to a diagnosis of paroxysmal nocturnal hemoglobinuria (PNH). An 82-year-old woman visited our hospital for chronic heart and renal failure. She had a history of breast cancer, myocardial infarction, and hemorrhoidal fistula and was initially hospitalized for ischemic colitis. Subsequent lower gastrointestinal endoscopy revealed extensive ulcerative lesions in the ascending, transverse, and descending colon. Histopathologically, small vessels exhibited multiple fibrin thrombus formations. Based on histopathological and endoscopic results, the presence of an underlying disease was suspected. Flow cytometric analysis showed that erythrocytes and granulocytes had 5.5 and 86.4% CD55- and CD59-negative cells, respectively. The patient was ultimately diagnosed with PNH and considered severely ill, given the ischemic colitis-induced abdominal pain and the need for red blood cell transfusions (4-6 units per month). Accordingly, the patient was administered ravulizumab. Ischemic enteritis did not relapse following ravulizumab administration, and transfusion dependence improved. If a patient with ischemic colitis presents atypical lower gastrointestinal endoscopic findings, it is important to explore the presence of an underlying disease.