Journal of Nippon Medical School
Online ISSN : 1347-3409
Print ISSN : 1345-4676
ISSN-L : 1345-4676
Advance online publication
Showing 1-24 articles out of 24 articles from Advance online publication
  • Yuji Tomori, Mitsuhiko Nanno, Shinro Takai
    Article ID: JNMS.2020_87-105
    Published: 2019
    [Advance publication] Released: October 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Purpose: Displaced lateral humeral condyle fractures in children are commonly fixed using Kirschner wires (K-wires). However, K-wire fixation alone is insufficient for early elbow range of motion (ROM) exercises. Comparatively, combined fixation with tension band wiring (TBW) converts distraction forces into compression forces, which provides more rigid fixation than K-wire fixation alone. Here, we retrospectively evaluated the clinical outcomes for patients with displaced lateral humeral condyle fractures treated with TBW or K-wires only.

    Materials and methods: We identified children with lateral condyle fractures who had undergone surgery from April 2000 to March 2014. Nineteen patients were classified into 2 groups according to treatment: 10 patients were allocated to the TBW group (TBW and K-wires), and 9 patients to the K-wires group. The mean time between injury and surgery was 5.1 days and 5.1 days in the TBW and K-wires groups, respectively. Fractures were classified using Jacob's and Milch's classifications. We recorded postoperative complications, radiological and clinical evaluations, ROM, and Flynn's criteria.

    Results: The mean follow-up time was 14.4 months and 5.9 months in the TBW and K-wires groups, respectively. The mean of bone union time was 38.6 days and 49.8 days in the TBW and K-wires groups, respectively. Patients in the K-wires group required a cast/splint for significantly longer than TBW patients (49.8 days vs. 35.8 days on average, respectively). Range of flexion was significantly decreased at the final follow-up in patients in the K-wires group.

    Conclusions: TBW fixation is probably optimal procedure for displaced lateral humeral condyle fractures in children, as it can promote early active range of motion exercise.

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  • Mitsuhiko Nanno, Norie Kodera, Yuji Tomori, Shinro Takai
    Article ID: JNMS.2020_87-106
    Published: 2019
    [Advance publication] Released: October 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Standard volar plating of distal radius fractures may not adequately fixate the volar lunate facet (VLF) fragment, leading to volar carpal subluxation. In this study, we hypothesized that the size of the VLF fragments distal to the watershed line might affect the reduction loss after distally placed volar locking plate fixation for intra-articular distal radius fracture, and aimed to prove that small displaced VLF fragments was a risk factor in causing reduction loss.

    Methods: Twenty-seven hands in 27 patients with intra-articular distal radius fractures with VLF fragments distal to the watershed line were treated using Acu-Loc 2 volar distal radius locking plate fixation.

    Results: At final follow-up, the mean Mayo Performance Score was 90.9 and the mean Quick Disabilities of Arm, Shoulder and Hand score was 13.6. On radiography, 5 patients had reduction loss of > 2 mm in ulnar variance from immediately postoperatively to final follow-up (group 1), while 27 had no reduction loss (group 2). Compared with group 2, the VLF fragment in group 1 had significantly smaller mean longitudinal, transverse, and anteroposterior lengths, and joint surface area. Three-dimensional computed tomography revealed that the fracture patterns of the radiocarpal and distal radioulnar joints in group 1 were mainly volar displaced VLF fragments.

    Conclusions: Distally placed volar locking plate fixation effectively treats intra-articular distal radius fractures with VLF fragments distal to the watershed line by stabilizing the fragments. However, small displaced VLF fragments may increase the risk of reduction loss in ulnar variance.

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  • Yasuyuki Kitagawa, Ryu Tsunoda, Mitsuhiko Nanno, Satoru Arai, Shinro T ...
    Article ID: JNMS.2020_87-201
    Published: 2019
    [Advance publication] Released: October 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Magnetic resonance imaging (MRI) and fine needle aspiration cytology (FNAC) help to diagnose soft tissue tumors and can be done on outpatients. The advantages and disadvantages of these modalities suggest that they could demonstrate a complementary relationship: MRI examines a general area, while FNAC assesses a highly specific region; MRI shows only signal intensities, while FNAC visualizes actual tumor cells. The present study was performed to investigate the application of this potential complementary relationship to facilitate differentiation of malignant and benign tumors.

    Methods: Both preoperative MRI and FNAC were performed in 148 patients (153 lesions: 137, benign; 16, malignant). The diagnosis was judged to be correct if one or both diagnoses were correct; it was incorrect if at least one diagnosis was incorrect; and was indeterminate if both diagnoses were indeterminate or, in the case of FNAC, insufficient due to sample aspiration insufficiency.

    Results: The diagnostic yields of MRI only, FNAC only, and the combination of MRI and FNAC were 81.7%, 84.3%, and 92.2%, respectively, indicating that the diagnostic utilities of both MRI and FNAC were significantly improved by their combined application.

    Conclusions: The combined preoperative application of MRI and FNAC improved diagnosis of soft tissue tumors relative to assessment with either modality alone.

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  • Katsumi Sasatani, Tokifumi Majima, Kohei Murase, Naoki Takeuchi, Takeo ...
    Article ID: JNMS.2020_87-202
    Published: 2019
    [Advance publication] Released: October 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Unicompartmental knee arthroplasty (UKA) has been becoming popular over the last decades for its good outcome. On the other hand, several accompanying complications have been reported. Tibial implant alignment is considered to be one of the important causes of these complications. There have been some reports about it, but an optimal alignment of the tibial implant is still controversial. The purpose of this study was to observe the changes in stress distribution in the proximal tibia after UKA at various tibial implant alignments by using 3-dimensional finite element analysis.

    Methods:A 3-dimensional finite element model was created with CT-DICOM data of a medial osteoarthritic knee. The change in stress distribution of tibial implant alignment in the coronal plane (middle position, varus 5°, valgus 5°) and in the sagittal plane (0°, 5°, 10°) under the conditions of loose boundary between implant and bone and no loosening condition was observed using 3dimensional finite analysis.

    Results: With no loosening, high stress distribution was observed at the lateral rim of the subchondral bone in the varus alignment model, and the high stress distribution was moving from anterior to posterior with the posterior tilting from 0° to 10°. With loosening, high stress distribution was observed at the proximal tibial medial cortex in the valgus alignment model.

    Conclusions: In UKA, optimal alignment of the tibial implant might be at the middle position in the coronal plane and at the posterior inclination similar to each patient's original inclination in the sagittal plane to reduce complications.

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  • Shunsuke Inage, Shotaro Nakamura, Yuto Isoe, Saori Okamoto, Sho Uetake ...
    Article ID: JNMS.2020_87-203
    Published: 2019
    [Advance publication] Released: October 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: We investigated the incidence of acute kidney injury (AKI) and the risk factors associated with vancomycin (VAN) and piperacillin-tazobactam (TZP) combination therapy in non-intensive care unit (ICU) and ICU settings.

    Methods: In this single-center retrospective cohort study, adult patients who received VAN for ≥ 48 h between 1 January 2016 and 31 December 2017 were included. The primary end point was the incidence of AKI.

    Results: A total of 593 adult patients were included. The incidence of AKI was 10.6% overall, 8.0% in the non-TZP group, and 19.8% in the TZP group. In a univariate analysis, the odds of AKI were higher in the TZP group than in the non-TZP group (odds ratio (OR) = 2.84, 95% confidence interval (CI) = 1.64-4.90). In both non-ICU and ICU settings, the odds of AKI were higher in the TZP group than in the non-TZP group (non-ICU: OR = 3.04, 95% CI = 1.52-6.09; ICU: OR = 2.51, 95% CI = 1.03-6.08). Furthermore, a propensity score analysis revealed that the odds of AKI were higher in the TZP group than in the non-TZP group (OR = 2.81, 95% CI = 1.52-5.17). In both non-ICU and ICU settings, the odds of AKI were higher in the TZP group than in the non-TZP group (non-ICU: OR = 2.57, 95% CI = 1.17-5.64; ICU: OR = 3.51, 95% CI = 1.05-11.6).

    Conclusions: The combined use of TZP in patients receiving VAN increased the incidence of AKI in both non-ICU and ICU settings.

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  • Yasuyuki Kitagawa, Toshihiko Ito, Yoshihiro Mizuno, Yoshihiro Sudo, Yo ...
    Article ID: JNMS.2019_86-609
    Published: 2019
    [Advance publication] Released: September 30, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: The number of patients with bone metastases is increasing in Japan as the population ages. A multidisciplinary approach for patients with bone metastases is important. Since 2014, our orthopedics department has undertaken activities, including giving lectures describing a multidisciplinary approach for bone metastases to hospital staff and holding regular cancer board meetings that focus on bone metastases, to promote a multidisciplinary approach in our hospital. This study aimed to investigate whether these activities have effectively promoted multidisciplinary approaches and improved the outcomes of patients with bone metastasis.

    Methods: To investigate the effects of changes in medical practice on patients with bone metastases, different clinical factors were compared between patients from a period after the start of the activity (PASA), i.e., January 2014 to December 2017, and patients from a period before the start of the activity (PBSA), i.e., January 2011 to December 2013.

    Results: The semiannual numbers of first-visit patients, referrals, and orthopedic surgical cases, and the numbers of patients with slower growing primary cancers and patients whose pain was milder were significantly higher during the PASA than those during the PBSA. The number of patients without paralysis tended to be higher during the PASA than during the PBSA. The survival periods after the first visit to the orthopedics department were significantly longer during the PASA than during the PBSA.

    Conclusion: A high potential demand exists for a multidisciplinary approach for bone metastases, and orthopedic specialists should actively participate in this approach.

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  • Yasuyuki Kitagawa, Yong Kim, Ryu Tsunoda, Shinro Takai
    Article ID: JNMS.2020_87-103
    Published: 2019
    [Advance publication] Released: September 30, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: It is important to know the natural history of retroperitoneal schwannoma including the growth rate in deciding the indication and timing of surgery in such nonpalpable tumors. However, the natural history of this tumor remains unclear. This study aimed to clarify the natural history and whether magnetic resonance imaging (MRI) findings and clinical findings can predict the future growth of this tumor.

    Materials and Methods: Of patients with retroperitoneal schwannoma treated in our department from January 1, 2015, to December 31, 2015, eight patients who were followed up by MRI and without removal for more than 1 year were enrolled. Changes in lesion size were examined in relation to some clinical and MRI findings. In cases with pressure erosion in the vertebral body, a change in the size of the intraosseous part was compared to a change in the size of the whole lesion.

    Results: The median absolute growth rate (AGR) was 1.9 cm3/year, the median relative growth rate (RGR) was 5.6%/year, and the median tumor volume doubling time (VDT) was 3.1 years. The AGR, RGR, and VDT were not related to any clinical findings. The intraosseous part showed RGR and VDT around twice that of the whole lesions.

    Conclusions: The growth rates of retroperitoneal schwannomas were various. Additionally, MRI findings and clinical findings that could predict the future growth of retroperitoneal schwannoma could not be clarified. Therefore, careful follow-up is necessary for this tumor, especially for lesions with bone erosion.

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  • Minoru Gotoh, Osamu Kaminuma, Akihiro Nakaya, Mayumi Saeki, Tomoe Nish ...
    Article ID: JNMS.2020_87-104
    Published: 2019
    [Advance publication] Released: September 30, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Basophils have been implicated not only in allergy pathogenesis, but also in the efficacy of allergen immunotherapy (AIT). We recently conducted a clinical study of sublingual immunotherapy (SLIT) in patients with Japanese cedar pollinosis using a purified cedar allergen. Patients were stratified into the high-responder (HR) and non-responder (NR) groups, and comprehensive microarray analysis was performed on peripheral basophils in the patients from both groups. A total of 153 genes were found to be differentially expressed in the HR and NR patients. The majority of the differentially expressed genes were intracellular molecules and showed higher expression levels in HR patients than NR patients. The mRNA expression levels of the gene encoding D4, zinc, and double plant homeodomain (PHD) fingers family 2 (DPF2) were found to be significantly correlated with copy number variation (CNV). Genetic variation in the DPF2 gene and its expression in basophils is a candidate determinant for SLIT efficacy.

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  • Tomokazu Motomura, Hisashi Matsumoto, Hiroyuki Yokota, Mototsugu Suzuk ...
    Article ID: JNMS.2019_86-607
    Published: 2019
    [Advance publication] Released: August 20, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Traumatic asphyxia is a major cause of death in fatal crowd disasters, but the relationship between compression site, load magnitude, load time, and the medical event remains unclear. This study sought to estimate thoracoabdominal compression conditions (load magnitude, load time) resulting in respiratory failure in adults.

    Methods: A total of 8 load patterns—A (chest load: 0 kg, abdomen load: 10 kg), B (0, 20), C (10, 0), D (10, 10), E (10, 20), F (20, 0), G (20, 10), H (20, 20) —were applied in 14 healthy adult female subjects. Blood pressure, heart rate, respiratory rate, SpO2, tidal volume, vital capacity, respiratory phase, and modified Borg dyspnea score were measured over time. The Breathing Intolerance Index (BITI) was also calculated.

    Results: Vital capacity decreased in patterns C, D, E, F, G, and H. BITI reached the critical range of ≥ 0.15, where respiratory failure occurs about 45 min later, after 14 min in pattern G and 2 min in pattern H. Vital capacity ≤ 1.85 L and modified Borg scale score  8.3 corresponded to BITI  0.15 and were regarded as equivalent to reaching the critical range. Furthermore, the change in chest load was positively correlated with BITI when abdominal load was kept constant.

    Conclusions: In human women, respiratory failure could occur within 1 h due to respiratory muscle fatigue even when the total thoracoabdominal load is only about 60% of the body weight. Vital capacity ≤1.85 L and modified Borg scale score ≥8.3 can be considered as indices for predicting respiratory failure.

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  • Noriyuki Kawami, Shintaro Hoshino, Yoshimasa Hoshikawa, Nana Takenouch ...
    Article ID: JNMS.2019_86-608
    Published: 2019
    [Advance publication] Released: August 20, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: In a previous study in healthy subjects, the cutoff value for integrated relaxation pressure (IRP) used in Starlet (high-resolution manometry system) was predicted to be about 26 mmHg. However, we encounter patients with achalasia whose IRP value is 26 mmHg. The purpose of this study was to examine the validity of the IRP cutoff value in Starlet for patients with achalasia.

    Methods: In 37 patients with achalasia, the percentage of patients whose IRP values in Starlet were 26 mmHg was calculated. In addition, the patients were divided into the IRP-high group (IRP 26 mmHg) and the IRP-low group (IRP 26 mmHg), and both groups were compared regarding basal lower esophageal sphincter (LES) pressure, achalasia subtypes in the Chicago Classification, and classification by esophagography.

    Results: Twenty (54%) of the 37 patients had an IRP 26 mmHg. The basal LES pressure in the IRP-high group was significantly higher than that in the IRP-low group. Type II achalasia in the Chicago Classification was most common in the IRP-high group, whereas type I was most frequent in the IRP-low group. No significant difference was noted in the distribution of subtypes in esophagography between the 2 groups.

    Conclusions: It is difficult to determine the IRP cutoff value using the Starlet. In diagnosis of achalasia using the Starlet, it is necessary to comprehensively judge the results other than IRP values. In addition, there was an association between IRP values and achalasia subtypes in the Chicago classification.

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  • Seiji Futagami, Hiroshi Yamawaki, Shuhei Agawa, Go Ikeda, Hiroto Noda, ...
    Article ID: JNMS.2020_87-101
    Published: 2019
    [Advance publication] Released: August 20, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Functional dyspepsia (FD) is a common disease that can markedly impair the patients' quality of life. In 2016, Rome IV criteria defined the diagnosis of functional dyspepsia as requiring bothersome FD symptoms. In 2009, a new diagnosis of early chronic pancreatitis (ECP) was proposed as a new strategy to address chronic pancreatitis at the initial phase and prevent it from advancing into chronic pancreatitis. Although chronic pancreatitis was reported to be one of the causes of dyspepsia, there was scant data regarding the relationship between ECP and FD patients. Therefore, we tried to investigate differences in the percentages of severe epigastric pain, early satiety and postprandial abdominal fullness between ECP patients and FD patients. Several studies have reported that the relationship between the etiology of chronic pancreatitis and endosonography features. In addition, endosonography was a useful tool to distinguish ECP patients from FD patients with pancreatic enzyme abnormalities. Thus, we compared the characteristics of endosonography features in ECP and FD patients with pancreatic enzyme abnormalities. Further studies will be warranted to clarify whether certain FD patients with pancreatic enzyme abnormalities will develop to ECP patients.

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  • Mitsuhiko Nanno, Norie Kodera, Yuji Tomori, Shinro Takai
    Article ID: JNMS.2019_86-507
    Published: 2019
    [Advance publication] Released: July 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: We compared the clinical results between a newly modified abductor pollicis longus (APL) suspension arthroplasty with trapeziectomy procedure (modified Thompson procedure) and the original APL suspension arthroplasty with trapeziectomy procedure (original Thompson procedure) for treatment of advanced osteoarthritis of the thumb carpometacarpal (CMC) joint and assessed the efficacy of the modified Thompson procedure for thumb CMC osteoarthritis.

    Methods: Ten hands of 10 patients (Group 1) were treated by the original Thompson procedure. Twenty hands of 16 patients (Group 2) were treated by the modified Thompson procedure, in which the bone tunnel positions were rearranged for passage of the transferred APL more dorsoradially than Group 1.

    Results: The thumb palmar and radial abduction angles; pinch power; grip strength; Quick Disability of Arm, Shoulder, and Hand questionnaire (Quick DASH) score; and visual analog scale (VAS) score were significantly different before and after surgery. There were no statistically significant differences in the thumb palmar abduction angle, pinch power, grip strength, Quick DASH score, or VAS score between Groups 1 and 2. However, patients in Group 2 had a significantly better range of motion of radial abduction in the thumb than those in Group 1.

    Conclusions: The modified Thompson procedure is a simple and effective technique that can improve the thumb radial abduction angle compared with the original technique in patients with advanced thumb CMC osteoarthritis. Additionally, this new technique is as useful as the original procedure in early restoring thumb function and relieving pain.

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  • Keigo Takahashi, Go Kimura, Yuki Endo, Jun Akatsuka, Tatsuro Hayashi, ...
    Article ID: JNMS.2019_86-602
    Published: 2019
    [Advance publication] Released: July 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Lipid cell variant of urethral carcinoma (UC) is a rare tumor and has been clinicopathologically poorly understood. A nodular tumor was detected in the bladder of an 87-year-old man with asymptomatic gross hematuria; the tumor was transurethrally resected. The patient was pathologically diagnosed with high-grade UC, lipid cell variant. The tumor cells, similar to lipoblasts, commonly contained cytoplasmic vacuoles. Immunohistochemically, the tumor cells were positive for epithelial markers such as CK7, 20, EMA, CAM5.2, and 34betaE12. However, they were negative for vimentin and S100. Moreover, focal positivity for adipophilin was detected in the cytoplasm, but not in the vacuoles. Based on these observations, we believe that the study patient could have lipid-producing UC.

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  • Masami Kashimura, Toshiaki Nomura, Akiko Ishiwata, Shin Kitamura, Aman ...
    Article ID: JNMS.2019_86-603
    Published: 2019
    [Advance publication] Released: July 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    This study investigated the feasibility of a cognitive behavioral therapy (CBT) program for a female patient with mild cognitive impairment (MCI), depression, and anxiety, to improve her mood and quality of life. The program comprised of eight 30-minute weekly sessions with interventions such as behavioral activation, relaxation, and cognitive reconstruction, in which the patient's caregiver also participated. An assessment evaluating the patient's condition were conducted before and immediately after the intervention. After 3 and 12 months, the caregiver reported the patient's behavioral and psychological symptoms using self-reported psychological scales concerning depression, anxiety, and quality of life. CBT helped to improve the patient's mood and quality of life in the short term (3 months). However, the results were not sustained in the long term (12 months). These results show that CBT could be a feasible non-pharmacological treatment option and provide preliminary support for wider application of CBT in Japan, even though it improved psychological symptoms in only one patient with MCI in the short term. Therefore, a CBT program should be tailored to meet the needs of patients with MCI and dementia, and regular follow-up sessions should be conducted to evaluate the feasibility of the program and the patient's mental health improvement.

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  • Yoshimasa Kanawaku, Youkichi Ohno
    Article ID: JNMS.2019_86-604
    Published: 2019
    [Advance publication] Released: July 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Objective: We reveal the actual situation of solitary death cases of Tokyo wards in 2015, by labor force status and welfare recipients, as social determinants of health.

    Methods: We obtained data on cases of solitary death in the 23 special wards of Tokyo in 2015. We also calculated the incident rate and postmortem interval of solitary death by sex, age, and labor force status.

    Results: In total, 3,972 solitary deaths (2,785 men, 1,187 women) were identified for analysis. The non-employed rate was 79.3% among men and 89.5% among women. The incidence among non-employed individuals was significantly greater than that among employed individuals for both sexes. Moreover, with the exception of women aged 65 years or older, the postmortem interval among non-employed individuals was significantly longer than that among employed individuals for both sexes.

    Conclusions: We showed that the incidences of solitary death are significantly higher among non-employed than employed individuals for both sexes, and postmortem intervals among non-employed are significantly longer.

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  • Hiroshi Mase, Yutaro Ogawa, Jumpei Takeuchi, Yuki Genda, Shingo Ichiba ...
    Article ID: JNMS.2019_86-606
    Published: 2019
    [Advance publication] Released: July 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Intravascular lymphoma is a rare disease exhibiting multiple organ dysfunction, mainly due to tumor cell proliferation in small blood vessels. Few reports exist on the critical care management of intravascular lymphoma. We describe a rare case of multiple organ failure due to intravascular lymphoma with severe lactic acidosis wherein the patient survived. A 64-year-old man had impaired consciousness and was diagnosed with intravascular large B-cell lymphoma through a random skin biopsy. The patient arrived at our hospital's intensive care unit (ICU) with impaired consciousness, respiratory failure that required mechanical ventilation, and lactic acidosis that required renal replacement therapy. His mechanical ventilation and renal replacement therapy continued in the ICU and eventually his respiratory status and circulatory dynamics stabilized. However, his level of consciousness and hyperlactatemia did not improve until after doxorubicin, cyclophosphamide, vincristine, prednisolone, and rituximab chemotherapy. Although he experienced tumor lysis syndrome immediately after chemotherapy, his systemic condition gradually stabilized through continued critical care management consisting primarily of renal replacement therapy. He was weaned from ventilator support after undergoing a tracheotomy and moved into the general ward. Hematopoietic malignancies with hyperlactatemia have very poor prognosis; however, this patient's hyperlactatemia and level of consciousness were dramatically improved by the critical care management and chemotherapy. We report a rare case in which a patient with intravascular lymphoma involving multiple organ failure survived.

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  • Yasuyuki Kitagawa, Takashi Yamaoka, Mari Yokouchi, Toshihiko Ito, Yosh ...
    Article ID: JNMS.2019_86-506
    Published: 2019
    [Advance publication] Released: June 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Our previous studies have shown that early diagnosis of painful bone metastasis is difficult and that it is necessary to improve the diagnostic accuracy of plain radiography during patients' first visit in order to make an early diagnosis. This preliminary study aimed to develop useful educational material for diagnosing bone metastasis using plain radiography. This study included a series of imaging data from 129 patients who had visited our orthopedic clinic from January 2011 to December 2014. First, we prepared a test to measure orthopedic practitioners' reading ability. Second, educational material was created. Third, the effectiveness of the educational material was verified by having orthopedic trainees take a pre-test and post-test. The test contained plain radiographic data of 12 patients with lesions and 6 without lesions. The educational material included plain radiographic data from 30 patients with typical findings of bone metastasis and diagnostic magnetic resonance imaging or computed tomography scans accompanied by a lecture. The accuracy and sensitivity of diagnosis significantly improved after the lecture; however, the specificity decreased. The educational material was effective for improving orthopedic trainees' reading ability of plain radiographic findings of bone metastasis; however, aspects of it still need to be improved and revised.

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  • Naoto Chihara, Nobuhiko Taniai, Hideyuki Suzuki, Ryosuke Nakata, Mio S ...
    Article ID: JNMS.2019_86-601
    Published: 2019
    [Advance publication] Released: June 15, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Complete surgical excision is the standard treatment for hydrocele of the canal of Nuck. Accordingly, we devised a novel open posterior wall technique for laparoscopic transabdominal preperitoneal (TAPP) excision.

    A 38-year-old woman presented to us with a 5-month history of a painless reducible lump in the right groin. She had recently noticed a slight increase in the size of the groin lump. Computed tomography (CT) showed a simple cystic lesion measuring 30 × 27.5 mm. We performed laparoscopic excision of the hydrocele via the TAPP approach, using an open posterior wall technique devised by us. Complete excision of the hydrocele was satisfactorily performed because the region from the external inguinal ring to the periphery could be clearly observed. The patient was discharged after an uneventful postoperative course. Laparoscopic TAPP excision using the open posterior wall technique was useful for complete excision of hydrocele of the canal of Nuck.

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  • Dai Namizato, Masae Iwasaki, Masashi Ishikawa, Ryuta Nagaoka, Yuki Gen ...
    Article ID: JNMS.2019_86-408
    Published: 2019
    [Advance publication] Released: May 17, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Intraoperative neuromonitoring (IONM) could reduce the incidence of injury to the recurrent laryngeal nerve (RLN) during thyroidectomy. Although the dislocation of endotracheal tube surface electrodes can lead to false positive IONM results (loss of signals), the risk factors remain unclear, as does the influence of muscle relaxants. Therefore, to identify factors that can affect IONM results, we examined the frequency and risk factors of tube dislocation after cervical extension prior to surgery, the effect of sugammadex administration, and the correlation between IONM results and postoperative RLN palsy.

    Methods: Thirty-nine patients scheduled for thyroidectomy from October 2016 to April 2017 were enrolled. All patients underwent standard IONM and pre- and postoperative laryngoscopy. Differences in patient characteristics between the tube dislocation group and the non-dislocation group, and differences in the amplitude at vagal stimulation between before and after sugammadex administration, were assessed by the Mann–Whitney test or Fisher's exact test.

    Results: Tube dislocation was observed in 27 patients (69%). The dislocation group (n=27) had a significantly shorter sterno-cricoid distance than the non-dislocation group (n=12) (43.88 (32.2–55.91) mm vs 49.46 (40.66–55.91) mm, respectively ;p=0.048). Without sugammadex, the amplitude at vagal stimulation was enough for monitoring. Nine patients had new-onset RLN palsy, but all of them were transient. The sensitivity of IONM was 100%, the predictive positive value was 60%, and the negative predictive value was 100%.

    Conclusions: This study suggested that anesthesiologists should correct tube dislocation reliably with video laryngoscope. The dose of rocuronium 0.6 mg/kg without sugammadex could be adequate for IONM.

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  • Tadashi Yokoyama, Hiroshi Makino, Atsushi Hirakata, Junji Ueda, Hideyu ...
    Article ID: JNMS.2019_86-502
    Published: 2019
    [Advance publication] Released: May 17, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    We report a case of metastatic pancreatic-head mucinous carcinoma (with multiple lymph node and bone metastases), as well as a literature review. Endoscopic ultrasound - fine needle aspiration (EUS-FNA) was useful for diagnosis in this patient, and a satisfactory outcome was achieved using systemic chemotherapy with FOLFIRINOX followed by resection of the primary lesion as conversion surgery. The patient was a 55-year-old man. Hematological findings included elevated serum tumor marker levels: CEA at 12.7 ng/ml and DUPAN-2 at 400 U/ml. With several modalities and EUS - FNA, the patient received a clinicopathological diagnosis of metastatic pancreatic mucinous carcinoma with multiple bone and lymph node metastases. For systemic chemotherapy, five courses of modified FOIFIRINOX (m-FFX) were given, and an antitumor effect was obtained; therefore, subtotal stomach-preserving pancreaticoduodenectomy and extensive lymph-node dissection were performed. Histopathologically, the results were invasive ductal carcinoma, muc (pT3, pN1b, cM1). After surgery, the clinical course was notable for the absence of complications. Tegafur/gimeracil/oteracil (S-1) was started as maintenance adjuvant chemotherapy postoperatively. And, the patient is still ongoing progression-free survival 10 months after the surgery.

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  • Masato Yoshioka, Nobuhiko Taniai, Youichi Kawano, Tetsuya Shimizu, Ryo ...
    Article ID: JNMS.2019_86-503
    Published: 2019
    [Advance publication] Released: May 17, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    The indocyanine green (ICG) fluorescence method is reportedly useful for intraoperative visualization of hepatocellular carcinoma and metastatic liver cancer. Herein, we report the case of a 73-year-old man who underwent laparoscopic hepatectomy using an ICG fluorescence navigation system. The patient had a surgical history of two laparotomies for hepatocellular carcinoma resection. During follow-up at our hospital, abdominal computed tomography revealed recurrence of hepatocellular carcinoma in the lateral area of the liver, and so the patient was hospitalized for surgery. Because of his surgical history, adhesions within the abdominal cavity were predicted. We scheduled laparoscopic repeat hepatectomy (LRH) using an ICG fluorescence method in which the ICG was injected intravenously 2 days before surgery. The ICG fluorescence was easily detected intraoperatively. The advantages of the present approach were: 1) inducing pneumoperitoneum and using laparoscopic magnification enabled good visualization of the surgical field for LRH; 2) use of the ICG fluorescence technique enabled clear intraoperative identification of the tumor, thus facilitating LRH. Laparoscopic partial resection of the liver (S3) was successfully performed, with an operation time of 197 minutes and a bleeding volume of 30 mL. The patient had an uneventful postoperative course and was discharged on postoperative day 10.

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  • Miwako Omori, Yoshinobu Saito, Yukiko Miura, Toru Tanaka, Takeru Kashi ...
    Article ID: JNMS.2019_86-504
    Published: 2019
    [Advance publication] Released: May 17, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    We report a case of pneumonitis with alveolar hemorrhage induced by herbal medicines. A 73-year-old female was admitted to our hospital due to dyspnea and the presence of an abnormal shadow on the chest roentgenogram. She had received treatment with numerous drugs, including the following herbal medicines: Seisin-renshi-in, Chotosan, Rikkunshi-to, and Shakuyakukannzo-to. Chest radiography revealed diffuse ground-glass shadows in both lungs. The bronchoalveolar lavage fluid was progressively bloody. In addition, culture did not show the presence of microorganisms in the fluid. Moreover, there were no findings suggestive of rheumatic disease or vasculitides. Based on this evidence, we suspected drug-induced diffuse alveolar hemorrhage. She discontinued the use of all previous agents, and received treatment with corticosteroids. Her respiratory condition and the chest roentgenogram improved. According to the timing of administration and rechallenge with other drugs, the herbal medicines were suspected to be the causative drugs. Among those, Seisin-renshi-in was the most suspicious. Firstly, Seisin-renshi-in contains Ougon (skullcap), which is known to cause pneumonitis. Secondly, a drug lymphocyte stimulation test was positive for Seisin-renshi-in. This is the first report indicating that Seisin-renshi-in may cause diffuse alveolar hemorrhage. Diffuse alveolar hemorrhage due to herbal medicines is a rare but emergent disorder. Therefore, treating physicians should be aware that herbal medicines, including Seisin-renshi-in, may cause diffuse alveolar hemorrhage.

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  • Takeshi Oba, Shunsuke Kobayashi, Yuko Nakamura, Mototsugu Nagao, Kanda ...
    Article ID: JNMS.2019_86-505
    Published: 2019
    [Advance publication] Released: May 17, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    A 21-year-old man presented with hyperthyroidism and hypokalemia and was treated for thyrotoxic hypokalemic periodic paralysis (THPP) due to Graves' disease. Thyroid function soon normalized, but hypokalemia persisted. Laboratory data revealed hyperreninemic hyperaldosteronism and metabolic alkalosis consistent with Gitelman's Syndrome (GS). He was found to have a previously unreported compound heterozygous mutation of T180K and L858H in the SLC12A3 gene and was diagnosed with GS. He was started on eplerenone to control serum potassium levels. It is important to consider other diagnoses when electrolyte imbalances persist despite resolving disease.

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  • Seitaro Nishimura, Masashi Utsumi, Hideki Aoki, Yuta Une, Hajime Kashi ...
    Article ID: JNMS.2018_86-501
    Published: 2019
    [Advance publication] Released: April 26, 2019
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    We report the case of a pancreatic ductal adenocarcinoma (PDAC) in the remnant pancreas of a 78-year-old man after pancreaticoduodenectomy for acinar cell carcinoma. Acinar cell carcinoma is a relatively rare pancreatic neoplasm. Following the diagnosis of pancreatic carcinoma, subtotal stomach-preserving pancreaticoduodenectomy was performed. The pathological diagnosis was acinar cell carcinoma of the pancreas, disease stage IA, pT1, pN0, M0, without regional lymph node invasion. Twenty-two months after the surgery, cancer antigen 19-9 levels gradually increased, and computed tomography showed 2 solid tumors, approximately 1.1 and 2.1 cm in diameter, respectively, at the site of the remnant pancreas. Endoscopic ultrasound fine-needle aspiration revealed pancreatic ductal adenocarcinoma. The tumor cells were not immunoreactive for trypsin. Both tumors were diagnosed as PDAC of the remnant pancreas. The patient refused treatment with curative resection. Thus, as an alternative treatment, chemoradiotherapy was initiated. However, 28 months after surgery, the patient succumbed to the disease. Because this is an extremely rare case, further cases and studies are needed to understand its pathogenesis.

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