Journal of Nippon Medical School
Online ISSN : 1347-3409
Print ISSN : 1345-4676
ISSN-L : 1345-4676
Advance online publication
Showing 1-50 articles out of 61 articles from Advance online publication
  • Aya Yamagishi, Nobuatsu Koyama, Naoyuki Yamashita, Mikito Suzuki, Take ...
    Article ID: JNMS.2021_88-413
    Published: 2020
    [Advance publication] Released: November 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    A 64-year-old female was admitted to the hospital with constant abdominal pain. She had been previously hospitalized five times in 2 years with similar symptoms. Computed tomography revealed dilatation and fecal impaction from the ileum to the transverse colon. A barium enema and simultaneous ileus tube radiography demonstrated a segment of narrow descending-sigmoid colon. Colonoscopy did not show any mucosal change. These symptoms did not improve with conservative therapy when a descending and sigmoid colectomy was performed. In terms of histology, there was a disappearance of ganglion cells, and axon of Meissner' s plexuses was present along with a decrease in the number of Auerbach' s plexuses. The definite diagnosis given was segmental hypoganglionosis (SH) of the colon. The postoperative course was uneventful, and the functional result was positive following 1 year postoperatively. SH is extremely rare; however, surgical intervention is expected to be of benefit. Therefore, it is important to keep SH in mind when treating patients with chronic obstruction in the left side of the colon as it can cause SH.

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  • Katsuhito Kashiwagi, Tadashi Maeda, Sadako Yoshizawa, Takahiro Sato, K ...
    Article ID: JNMS.2021_88-417
    Published: 2020
    [Advance publication] Released: November 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    We assessed the relationship between disease severity and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) load, IgG antibody levels, and prognostic indicators. Twenty-one patients hospitalized with COVID-19 were classified as having severe or mild disease based on their average respiratory rate during hospitalization (severe: ≥22 breaths/min; mild: <22 breaths/min). The viral load in nasopharyngeal samples, and blood levels of C-reactive protein (CRP), lymphocytes, and D-dimer on admission and plasma immunoglobulin G (IgG) index on Day 7 ±2 from symptom onset were compared according to disease severity. Of the participants, 7 had severe and 14 had mild disease. Participants with severe disease had a significantly higher IgG index (median: 3.75 vs 0.56, p=0.01), CRP (median: 8.6 vs 1.0 mg/dL, p<0.001), and D-dimer levels (median: 1.65 vs 0.75μg/mL; p=0.002), and a significantly lower lymphocyte count (median: 1176 vs 666 cells/μL, p=0.005) and viral load (median: 8.7×106 vs 2.3×104 copies/mL, p=0.005). Furthermore, time from symptom onset to virus disappearance was significantly longer (median: 24 vs 17 days, p=0.03). A high IgG index in the early phase of the disease may be associated with disease severity and might serve as a prognostic indicator.

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  • Kenji Suzuki, Takashi Sasaki, Yasuo Miyagi, Keisuke Mori, Hiroaki Kish ...
    Article ID: JNMS.2021_88-507
    Published: 2020
    [Advance publication] Released: November 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Postoperative pain management in thoracotomy patients often is difficult. Furthermore, pediatric patients present more challenges because of their inability to effectively communicate their pain intensity. The purpose of this study was to evaluate the use of continuous field block through intercostal muscles as postoperative pain management in pediatric thoracotomy.

    Methods: Between 2014 and 2018, 11 patients underwent an ASD closure using a cardiopulmonary bypass via a mini-right thoracotomy through the fourth intercostal space. At the time of chest closure, a single-shot field block via the fourth intercostal muscles was performed with levobupivacaine (0.6 mg/kg). The first five patients were only given the single-shot field block (Single group). The remaining six patients were given levobupivacaine continuously (0.1 mg/kg/hr) through an indwelling catheter until the chest tube removal (Continuous group). The groups' vital signs, total amounts of acetaminophen used, postoperative courses were compared.

    Results: Although the heart rate did not differ between the groups, the respiratory rate was significantly higher in the Single group versus the Continuous group at 16 and 32 hr post-surgery (35.6±9.7/min vs. 18.5±4.7/min; p=0.007, 43.0±10.4 vs. 25.3±3.1; p=0.042, respectively). The accumulated dosage of acetaminophen given by postoperative day 2 was significantly higher in the Single group versus the Continuous group (55.3±22.1 mg/kg vs. 7.8±17.4 mg/kg; p=0.012).

    Conclusions: Continuous field block via intercostal muscles after ASD closure via a mini-right thoracotomy in children was effective to stabilize the vital signs and reduce the analgesic medication use.

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  • Yuji Hayashi, Hiroyuki Takei, Tsuyoshi Saito, Toshihiro Kai, Kenichi I ...
    Article ID: JNMS.2021_88-509
    Published: 2020
    [Advance publication] Released: November 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Neoadjuvant endocrine therapy is not the standard of care for breast cancer primarily because the optimal treatment duration remains unclear. This phase 2 prospective multicenter study analyzed time to progression, time to maximal response, and time to treatment failure of neoadjuvant exemestane.

    Methods: Inclusion criteria were women aged ≥ 60 years with Stage II or III breast cancer classified as estrogen receptor–positive / human epidermal growth factor receptor 2–negative. Response was defined as a ≥ 10% (minimum of 3 mm) decrease in tumor size compared with the most recent or smallest value, and progression was defined either a new lesion or a ≥ 10% (minimum of 3 mm) increase in tumor size compared with the most recent or smallest value. Maximal response was defined as the final recorded response.

    Results: This study included 24 women, most of whom had T2 N0 tumors with high estrogen receptor expression. We initially observed a response in 23 patients (96%); however, 6 patients (25%) later experience progression. Time to progression, time to maximal response, and time to treatment failure ranged from 7 to 22 months (estimated median, 35), 1 to 22 months (estimated median, 10), and 2 to 22 months (estimated median, 22), respectively. Treatment durations varied widely, but the estimated optimal duration of neoadjuvant exemestane therapy was 22 to 35 months in patients seeking to avoid surgery and 10 months in patients wishing to receive breast-conserving surgery.

    Conclusions: Neoadjuvant exemestane therapy is an effective strategy in older women with hormone-sensitive breast cancer.

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  • Tomonori Morita, Makiko Yamamoto, Atsuhiro Sakamoto
    Article ID: JNMS.2021_88-510
    Published: 2020
    [Advance publication] Released: November 30, 2020
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    Background: The incidence and risk factors of postoperative nausea and vomiting (PONV) and early PONV (ePONV) was evaluated in patients who underwent breast surgery with volatile anesthesia.

    Methods: In this retrospective study, we used a multivariate logistic regression to investigate the incidence and risk factors of PONV.

    Results: Among 928 patients, 166 (18%) and 220 (24%) had ePONV and PONV, respectively. In the multivariate analysis, the anesthesia duration and the use of desflurane were independent risk factors for ePONV. For PONV, the anesthesia duration and Apfel score were the independent risk factors.

    Conclusions: Although many previous studies have shown that PONV is a multifactorial event, our results indicate that desflurane use can be considered a main cause of ePONV. However, in the delayed phase, a higher Apfel score was the main predictor. In the early and delayed phases, a long duration of anesthesia was related to a high risk of PONV. Accordingly, avoiding a long duration of anesthesia and desflurane use is recommended for patients at a high risk of developing PONV, particularly for those with high Apfel scores.

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  • Kazutaka Kiuchi, Masato Matsushita, Masamichi Takano, Yasushi Miyauchi ...
    Article ID: JNMS.2021_88-511
    Published: 2020
    [Advance publication] Released: November 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    A 79-year-old man, with a history of atrial fibrillation, presented with a sudden onset of intermittent claudication of the left lower limb. The angiogram revealed a thrombotic total occlusion in the left superficial femoral artery (SFA). A 10-Fr sheath was antegradely inserted into the left common femoral artery (CFA), and the guidewire penetrated the lesion. Thrombo-aspiration using the 8-Fr long sheath into the 10-Fr short sheath was performed repeatedly. Intravenous anticoagulant was administrated immediately after the endovascular treatment. Follow-up angiogram performed 12 days after the procedure confirmed the absence of any residual thrombus in the SFA. Thrombo-aspiration, using a large-diameter catheter, is a feasible strategy for the treatment of acute and subacute limb ischemia, and is cost-effective.

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  • Nobuyuki Sakurazawa, Hiroki Arai, Tomohiko Yasuda, Komei Kuge, Shou Ku ...
    Article ID: JNMS.2021_88-512
    Published: 2020
    [Advance publication] Released: November 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Various types of obstruction can occur after a gastrectomy for gastric cancer. If proper treatment is not performed, such obstructions can lead to serious conditions. Early postoperative Roux limb torsion is a rare complication, and few reports of endoscopic treatment for this complication have been made. In the present report, we describe the endoscopic detorsion of Roux limb torsion in two patients. The first case was a 77-year-old woman who underwent a laparoscopic distal gastrectomy with Roux-en-Y (R-Y) reconstruction for early gastric cancer and a laparoscopic ileocecal resection (ICR) for early colorectal cancer. On the 12th day after the gastrectomy, a Roux limb torsion was observed. Endoscopic detorsion was performed, and the patient recovered. She was discharged on postoperative day 40. The second case was a 73-year-old man who underwent a laparoscopic-assisted total gastrectomy with a R-Y reconstruction for early gastric cancer. On the 8th day after the gastrectomy, a Roux limb torsion occurred at the Y-shaped anastomosis (Y-anastomosis). Endoscopic detorsion was performed, and the patient recovered. He was discharged on postoperative day 17. In summary, we experienced two cases in which an endoscopic reduction of a Roux limb torsion was performed at the Y-anastomosis after gastrectomy with R-Y reconstruction. This study presents a further review of these cases and a summary of the existing literature.

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  • Jun Kuwabara, Satoshi Akita, Mitsunori Sato, Katsuya Watanabe, Takayas ...
    Article ID: JNMS.2021_88-513
    Published: 2020
    [Advance publication] Released: November 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Wilms tumor (WT) is the most common malignant kidney tumor in children. High blood pressure is seen in up to 55% of children with WT. However, hypertensive cardiomyopathy with congestive heart failure due to WT is remarkably rare, with only several cases reported worldwide. In this report, a pediatric case of WT with hypertension causing hypertensive cardiomyopathy and congestive heart failure is presented. An 8-month-old male child with abdominal distension was seen by his primary physician. He was referred to our hospital for further examination and treatment. Abdominal contrast-enhanced computed tomography demonstrated a weakly enhancing, large abdominal mass, which was larger than 12 cm. Two-dimensional transthoracic echocardiography showed a diffuse hypokinetic left ventricle. The patient was diagnosed with cardiomyopathy caused by hypertension. Open surgical resection of the mass was successfully performed. His postoperative course was uncomplicated, and the patient was successfully discharged. The plasma renin activity was maintained at a high level even after left nephrectomy, suggesting that the right kidney was likely the source of renin secretion. Mechanical compression of the right renal blood vessels by a greatly enlarged left kidney can cause right renal ischemia, which activates renin excretion. Nephrectomy can be an effective treatment for a WT patient with hypertension causing hypertensive cardiomyopathy, and then cardiac function will be improved within several weeks. We recommend routine echocardiography surveillance in patients with WT. This report can help pediatric surgeons become more familiar with cardiomyopathy caused by WT.

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  • Mikito Suzuki, Katsuji Okada, Nobuatsu Koyama, Naoyuki Yamashita, Aya ...
    Article ID: JNMS.2021_88-514
    Published: 2020
    [Advance publication] Released: November 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    The gastrointestinal tract is not a common site for metastasis from lung cancer, and colonic metastases are especially rare. Although surgical intervention can improve colonic obstruction, perioperative mortality is high in patients with advanced malignancy, and these patients experience a significant deterioration in quality of life postoperatively. This report describes an uncommon case of colonic metastasis from non-small cell lung cancer (NSCLC), in which colonic obstruction was improved with a self-expanding metallic stent.

    A 62-year-old man was admitted to our hospital for progressively worsening abdominal pain. He had been treated with immunotherapy and chemotherapy after being diagnosed with NSCLC (T4N2M1) 1.5 years earlier. Enhanced computed tomography showed intestinal obstruction and a mass in the colon at the hepatic flexure. Histopathological analysis of a biopsy specimen confirmed NSCLC metastasis. Considering his general condition, endoscopic stenting was chosen as an urgent decompression procedure. He was discharged 45 days after stenting and was able to resume immunotherapy.

    Emergent stenting could be offered at experienced centers when operative intervention is not part of the treatment plan, as it is safe and improves the efficiency of care along with the quality of life.

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  • Yuichi Onishi, Katsunaka Mikami, Keitaro Kimoto, Natsuru Watanabe, Yuk ...
    Article ID: JNMS.2021_88-108
    Published: 2020
    [Advance publication] Released: September 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    To date, the efficacy and safety of the use of antipsychotics in children and adolescents have not been fully established. Although approved for use in adults, many antipsychotics are prescribed to children and adolescents in an off-label manner, at the discretion of individual physicians. This study aimed to identify the efficacy and tolerability of different antipsychotics in children and adolescents with schizophrenia or bipolar disorder. We conducted a literature review of the empirical evidence for the use of antipsychotics, particularly second-generation antipsychotics, in children and adolescents. The empirical evidence showed that antipsychotic use among children and adolescents was safe and efficacious. The efficacy of antipsychotics in the treatment of children and adolescents with schizophrenia or bipolar disorder was almost similar. When prescribing antipsychotics to children and adolescents, clinicians should consider adverse events and/or the discontinuation rate in treated patients. However, based on current evidence, it appears difficult to reach a consensus on the use of antipsychotics in children and adolescents.

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  • Kenichiro Atsumi, Yoshinobu Saito, Toru Tanaka, Takeru Kashiwada, Hiro ...
    Article ID: JNMS.2021_88-411
    Published: 2020
    [Advance publication] Released: September 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Measuring lung compliance is useful for evaluating interstitial lung disease (ILD) progression because reduced lung compliance by fibrosis progression is the main primary cause of decreased vital capacity. However, because of the invasiveness of the method, requiring the insertion of a balloon into the esophagus, lung compliance is rarely measured. A recently developed, possible method estimates intrathoracic pressure using fingertip photoplethysmography. This method non-invasively measures the lung dynamic compliance (Cdyn) by simultaneously measuring tidal volume. We evaluated the efficacy of this method in assessing ILD. Methods: We conducted a single-center, observational cross-sectional study to evaluate the efficacy of this method in subjects with ILD as compared with that in healthy control subjects. The main outcome was the estimated Cdyn (eCdyn) determined using this method. We also evaluated potential confounding factors of eCdyn in the baseline characteristics. Results: In the ILD group (n = 14) the median eCdyn was significantly lower than that in the control group (n = 49) (0.122 vs. 0.183; P = 0.011). In univariate regression analysis, eCdyn was significantly correlated with height, weight, forced vital capacity, forced expiratory volume in one second, diffusing capacity for carbon monoxide, and usual interstitial pneumonia (UIP). In multivariate regression analysis, both weight (β = 0.49, P = 0.011) and UIP (β = 0.52, P = 0.007) were significantly associated with eCdyn. Conclusions: We demonstrated a significant reduction in Cdyn in subjects with ILD using photoplethysmography. This non-invasive method might be a novel, promising tool for evaluating fibrosis progression in ILD.

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  • Yasufumi Yamada, Kazuhiko Yoshimatsu, Hajime Yokomizo, Sachiyo Okayama ...
    Article ID: JNMS.2021_88-415
    Published: 2020
    [Advance publication] Released: September 30, 2020
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    Background: Benefit of chemotherapy for patients with metastatic colorectal cancer is well known, however, that for those patients with poor performance status is little known.

    Patients and methods: We retrospectively evaluated efficacy of chemotherapy with capecitabine and bevacizumab for patients with poor PS (PS 3).

    Results: Seven patients were included and the median age of the patients was 82 years (range, 65–91 years). The response was not ascertained; nonetheless, the disease control rate was 83.3%. The median PFS and OS were 10.0 and 25.8 months, respectively. Hand foot syndrome (HFS) was the most common toxicity observed (three patients; 42.9%). Grade 3 toxicities were found in one patient with proteinuria and one with hypertension.

    Conclusion: This limited study indicated that chemotherapy using capecitabine and bevacizumab for patients with poor PS may provide favorable OFS and OS. Needless to say, we should be careful not to impose extra burden to patients with poor PS.

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  • Yuji Tomori, Norio Motoda, Mitsuhiko Nanno, Tokifumi Majima
    Article ID: JNMS.2021_88-416
    Published: 2020
    [Advance publication] Released: September 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Ganglion cysts are common benign lesions in the hand and wrist. However, intratendinous ganglion cysts are fairly rare lesions. We present the case of a 73-year-old woman with an intratendinous ganglion cyst occurring in the extensor pollicis longus (EPL) tendon of her right hand. The subcutaneous mass moved according to the movement of the EPL tendon of her right thumb. Magnetic resonance imaging showed a space-occupying lesion in the EPL tendon. Biochemical and hematoimmunological examinations ruled out diabetes mellitus, rheumatoid arthritis and other connective tissue diseases. She complained of a motion pain during thumb extension, and she had desired surgery. Intraoperatively, an intratendinous cyst was identified 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 remarkable proliferative synovial tissue. The EPL tendon was opened longitudinally, and a cystic lesion was enucleated. The pathological findings showed that the cyst wall consisted of fibrous tissue with degeneration, lacking epithelial lining. Postoperative recovery was uneventful. Six months after surgery, the patient had no residual pain and cyst recurrence. The rarity of intratendinous ganglion cysts makes diagnosis and treatment challenging. Since intratendinous ganglion cysts and associated synovitis frequently weaken the structure of the affected tendons, prompt diagnosis and surgical excision are necessary.

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  • Daisuke Nakajima, Hiroshi Takahashi, Shinichirou Kobayakawa
    Article ID: JNMS.2021_88-504
    Published: 2020
    [Advance publication] Released: September 30, 2020
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    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 ComfortIOL implantation.

    Conclusion: Lentis Comfort IOLs provided better visual function at far and intermediate distances.

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  • Kazuhiro Harada, Kenji Takahashi, Futoshi Ikuta, Yasuhiro Shindo, Kazu ...
    Article ID: JNMS.2021_88-505
    Published: 2020
    [Advance publication] Released: September 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: This study sought to assess the efficacy of a deep-tissue thermal therapy system with a resonant cavity applicator (DTT-RCA), which safely heats deep joint tissue for treating osteoarthritis (OA) of the knee.

    Methods: Two groups of participants were recruited. The DTT-RCA group comprised 20 knees. Kellgren-Lawrence (K-L) grade was I and II in 8 knees (DTT-RCA I/II group) [mean age 73.3 years (standard deviation 11.4) ], III and VI in 12 knees (DTT-RCA III/IV group) [75.4 (8.6) years]. The control group comprised 13 knees [68.2 (10.8) years]. K-L grade was I in 7 knees and II in 6 knees. This group received exercise therapy. The DTT-RCA I/II group and the control group were imaged by MRI T2 mapping at baseline and 6 months to determine the area of cartilage degeneration.

    Results: Visual Analogue Scale improved only in the DTT-RCA I/II post-intervention (p < 0.01). Japanese Orthopedic Association knee rating scores (DTT-RCA I/II: p < 0.01, control group: p < 0.01), the Japanese Knee Osteoarthritis Measure (DTT-RCA I/II: p < 0.05, control: p < 0.01), and the Knee injury and Osteoarthritis Outcome Score (DTT-RCA I/II: p < 0.01, DTT-RCA III/IV: p < 0.05, control: p < 0.01) post-intervention. The magnitude of change did not differ significantly between the three groups. The area of cartilage degeneration did not change significantly post-intervention in the DTT-RCA I/II group, not even relative to the control group.

    Conclusions: This was the first study to test a DTT-RCA system in patients with knee OA. The system reduced the clinical symptoms of knee OA and could potentially be effective for conservative therapy.

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  • Ami Shibata, Fumihiro Matano, Nobuyuki Saito, Yu Fujiki, Hisashi Matsu ...
    Article ID: JNMS.2021_88-506
    Published: 2020
    [Advance publication] Released: September 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background:

    Initial management of severe traumatic brain injury (TBI) is important, and includes treatment decision-making and prediction of prognosis. We examined whether biomarkers at admission could be useful prognostic predictors. We focused on electrolytes and blood glucose, which can be measured easily at any facility and for which the results can be obtained promptly before those of other biomarkers, such as D-dimer.

    Methods:

    All trauma patients with head injury treated at Chiba Hokusoh Hospital between 2014 and 2017 were investigated. Multiple trauma cases accompanied by fatal trauma, hemorrhagic shock, and cardiopulmonary arrest, and pediatric cases were excluded from this study. The blood gas data at the initial hospital visit were reviewed retrospectively. Cases in which the patients died or were in a vegetative state due to a head injury during hospitalization were defined as having a poor outcome. Factors related to poor outcome were analyzed.

    Results:

    Of 185 male and 79 female patients enrolled in the study, 34 had a poor outcome. Poor outcome was correlated significantly with potassium (P = 0.003), glucose (P < 0.001), and the glucose-to-potassium ratio (P < 0.001) at arrival. In particular, the odds ratio for a glucose-to-potassium ratio of ≥50 was 4.079.

    Conclusions:

    We evaluated blood gas data at initial hospital visit as these results can be obtained more quickly than those of other biomarkers assessed previously. Serum glucose-to-potassium ratio at admission may be a potential predictor of prognosis for severe TBI.

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  • Hirofumi Obinata, Shoji Yokobori, Kei Ogawa, Yasuhiro Takayama, Shuich ...
    Article ID: JNMS.2021_88-107
    Published: 2020
    [Advance publication] Released: August 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Coronavirus disease 2019 (COVID-19) and heat related-illness are systemic febrile diseases. In the summer during the COVID-19 pandemic, a differential diagnosis between the two conditions is important. However, no studies have compared and distinguished heat-related illness from COVID-19. We aimed to compare the data between patients with early-stage heat-related illness and those with COVID-19.

    Methods: This retrospective observational study included 90 patients with early-stage heat-related illness selected from Heatstroke STUDY 2017-2019 (nationwide registries of heat-related illness in Japan) and 86 patients with laboratory-confirmed COVID-19 with complaints of fever or fatigue and were admitted to one of two hospitals in Tokyo, Japan.

    Results: Amongvital signs, systolic blood pressure (119 vs. 125 mmHg, p = 0.02), oxygen saturation (98% vs. 97%, p < 0.001), and body temperature (36.6 vs. 37.6 °C, p<0.001) showed significant between-group differences for the heatstroke and COVID-19 groups, respectively. Numerous intergroup differences in laboratory findings were present, including white blood cell counts (10.8 vs. 5.2 × 103/μL, p<0.001), creatinine (2.2 vs. 0.85 mg/dL, p<0.001), and C-reactive protein (0.2 vs. 2.8 mg/dL, p<0.001), although a logistic regression model achieved an area under the curve (AUC) of 0.966 using these three factors. A Random Forest machine learning model achieved accuracy, precision, recall, and AUC of 0.908, 0.976, 0.842, and 0.978, respectively. Creatinine was the most important feature of this model.

    Conclusions: Acute kidney injury was associated with heat-related illness, which could be key in distinguishing or evaluating patients with fever in the summer during the COVID-19 pandemic.

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  • Chengbo Tan, Zifeng Wang, Miao Zheng, Songji Zhao, Hideo Shichinohe, K ...
    Article ID: JNMS.2021_88-308
    Published: 2020
    [Advance publication] Released: August 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Stroke is a leading cause of death and disability worldwide. Recently, brain secondary damage has been hypothesized to be a key aggravating element in an ischemic cascade. However, the interaction between cerebral infarction and immune organs has yet to be fully understood. In this study, we investigated the changes in the rat brain, spleen, thymus, mesenteric lymph node, and liver at 3, 7, and 13 days after transient middle cerebral artery occlusion (tMCAO) by immunohistochemistry.

    Material and methods: Rat models of stroke were made by tMCAO. Functional assessment was performed 3 h, and 1, 3, 5, 7, 9, 11, and 13 days after MCAO. Rat organs were harvested for 2,3,5-triphenyltetrazolium chloride staining and Immunohistochemistry.

    Results: The CD8α+ T cells was found to decrease in the spleen, thymus, mesenteric lymph node, and liver, whereas it increased in the brain. Those of Iba1+ and CD68+ macrophages were decreased in the spleen, thymus, and mesenteric lymph node, whereas they were elevated in the brain and liver. Ki67+ cells showed the same characteristics as macrophages, and increased numbers of terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) positive apoptotic cells were found in the spleen, mesenteric lymph node, liver, and brain.

    Conclusions: The present results demonstrated that stroke is a systemic disease, which not only affects the brain, but also induces responses of immune organs. On the basis of these results, a systemic treatment might be a good strategy for clinical stroke care.

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  • Daisuke Kakinuma, Yoshikazu Kanazawa, Kunihiko Matsuno, Yuka Masuda, F ...
    Article ID: JNMS.2021_88-310
    Published: 2020
    [Advance publication] Released: August 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Chylous ascites associated with radical resection of gastric cancer is a serious clinical condition. Lymph node dissection is indispensable during gastrectomy for gastric cancer. However, postoperative chylous ascites prolongs the hospital stay and re-operation. There are few reports on this subject. Most of these ascites cases usually subside untreated, but can cause significant morbidity. However, the definition of chylous ascites is ambiguous, and the reports on it in English literature vary.

    In this report, we discuss a 68-year-old man who underwent distal gastrectomy for early gastric cancer at our hospital who was admitted 8 months after the surgery with a main complaint of abdominal swelling. An abdominal puncture helped to diagnose him with chylous ascites with markedly elevated triglyceride levels. The patient received a hypercaloric infusion through a central line, and octreotide acetate, but without improvement in the patient's condition. After assessment of the lymph outflow using lymph scintigraphy, surgical ligation of the lymph vessels was performed through laparotomy. The volume of the milky-white ascites was 3,000 ml in the abdominal cavity. Macroscopically, a milky white fluid was confirmed as flowing from behind the common hepatic artery, and ligation was consequently performed. The patient's chylous ascites has not recurred in the 12 months after the re-operation.

    In summary, we discuss a case of postoperative chylous ascites after radical gastrectomy for gastric cancer that was successfully treated through surgery. We further review and report on the existing literature on this subject.

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  • Jun Kuwabara, Satoshi Akita, Mitsunori Sato, Katsuya Watanabe, Kazufum ...
    Article ID: JNMS.2021_88-311
    Published: 2020
    [Advance publication] Released: August 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Rubinstein–Taybi syndrome is an extremely rare autosomal dominant genetic disorder that occurs in 1/125,000 and is characterized by distinctive facial appearance, short stature, mild to severe mental retardation, and higher risk for cancer. In addition, variable organ anomalies had been reported. Paraovarian cyst causing torsion of the ipsilateral fallopian tube is less common, with an estimated incidence of 1/1,500,000, but it can adversely affect tubal function. It occurs mainly in women in the reproductive age and is very rare in prepubescent girls. Here, we described the successful treatment of an extremely rare case of paraovarian cyst causing torsion of the ipsilateral fallopian tube in a patient with Rubinstein–Taybi syndrome. A 14-year-old girl with Rubinstein–Taybi syndrome was referred to our hospital for abdominal pain. Her medical history was unremarkable, except for moderate hirsutism and keloid scar. Physical examination revealed tenderness in the lower abdominal midline. The preoperative diagnosis was torsion of a left ovarian cyst. An exploratory laparoscopy was performed because of acute abdominal pain and revealed a left fallopian tube that was twisted twice due to an ipsilateral paraovarian cyst. The huge paraovarian cyst required laparotomy cystectomy, and the left ovary was preserved. Her postoperative course was uncomplicated. Preoperative diagnosis of paraovarian cysts can be difficult. The moderate hirsutism seen in our patient suggested the presence of a large paraovarian cyst due to androgen receptor-mediated effects. Therefore, Rubinstein–Taybi syndrome patients with hirsutism should be screened and assessed by pediatric surgeons for the presence of paraovarian cysts.

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  • Kazuhisa Fujimoto, Hanao Yamaguchi, Yohei Otsuka, Nobuko Mayumi, Hideh ...
    Article ID: JNMS.2021_88-312
    Published: 2020
    [Advance publication] Released: August 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    We report a case of contact dermatitis caused by both efinaconazole, a topical triazole antifungal drug, and luliconazole, a topical imidazole antifungal drug. Positive patch test reactions were observed with efinaconazole and luliconazole. A patch test with lanoconazole also elicited a positive reaction. We hypothesized that structural similarity between luliconazole and lanoconazole led to cross-reaction, and that the dithiolane ring common to both drugs or the structure of the vinyl imidazole with a dithiolane ring could be the antigenic determinant.

    Since efinaconazole and luliconazole have no common structures, patients could be sensitized to both drugs separately. The antigenic determinant of efinaconazole is unknown. However, the chemical formula of ravuconazole, an oral triazole antifungal drug, is similar to that of efinaconazole. Clinicians should carefully consider potential cross-reactivity between these drugs.

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  • Shunichi Nomoto, Rei Ogawa
    Article ID: JNMS.2021_88-313
    Published: 2020
    [Advance publication] Released: August 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Objective: Various skin incision methods have been reported for reduction mammoplasty and mastopexy. The aim of our study was to develop a better method by improving conventional methods, with particular focus on the prevention of hypertrophic scars.

    Methods: We developed a comma-shaped incision method that would result in fewer scars and less strain on the suture line. We then applied this new design to two cases of breast reduction and breast fixation.

    Results: In both cases, we achieved good results. There was no scar at the inframammary fold, and no hypertrophic scar was formed. All scars were within the breast area and were not in contact with the brassiere wire; hence, there was less pain after the operation.

    Conclusions: We developed a new incision method for reduction mammoplasty and mastopexy, and it is a suitable option for use in these procedures.

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  • Yuji Tomori, Mitsuhiko Nanno, Sonoki Kentrao, Tokifumi Majima
    Article ID: JNMS.2021_88-314
    Published: 2020
    [Advance publication] Released: August 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Posttraumatic malunion of the phalanx with rotational deformity may cause crossing of the finger and impair hand function. Cosmetic disfigurement and severe dysfunction of the fingers require surgical correction, most often via open corrective osteotomies and rigid fixation with plates. However, such an approach requires a longer incision, inevitably results in a scar, and has a higher potential for extensor tendon adhesions, which result in extension lags. Also, abruption of the periosteum and plating of the phalanges require longer bone healing time. The purpose of the present study is to present an easy-to-use and minimally invasive correction of phalangeal malunions using a mini external fixator. In this procedure, a digital block of the affected finger can be performed. The fully flexed position of all fingers provides accurate correction of phalangeal malunions. Although the treatment of phalangeal malunions is still challenging, the procedure introduced in this study is an alternative solution for phalangeal malunions.

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  • Toru Igarashi, Syuji Takei, Eriko Tanaka, Utako Kaneko, Tomohiro Kubot ...
    Article ID: JNMS.2021_88-407
    Published: 2020
    [Advance publication] Released: August 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Regular assessment of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA) is essential for detecting glucocorticoid-induced osteoporosis in juvenile-onset autoimmune diseases. Z-score is used in children for standardization of osteoporosis assessment. Z-score in children can be evaluated with only one of the three models in Japan. The purpose of this study was to investigate how many domestic medical facilities for pediatric rheumatic diseases could not evaluate osteoporosis using Z-score exist.

    Methods: Electronic questionnaires were distributed between 2017 and 2019 to hospitals belonging to the Pediatric Rheumatology Association of Japan and to university hospitals and public children' s hospitals that provide medical care for pediatric rheumatic diseases. The questionnaire included the location of DXA measurement, manufacturer (Hologic, GE healthcare, Hitachi), and measurement site, and the answers were collected using Google Forms. Statcel 4 was used for analysis.

    Results: Overall,120 facilities responded to the survey, of which 117 had DXA. In the remaining three facilities, DXA was not installed in two and was out of order in one. Bone loss in childhood was evaluated using a Z-score calculated from age-based reference values. It was revealed that 30% of hospitals without HOLOGIC DXA could not evaluate osteoporosis by Z-score in Japanese childhood. The characteristics of the hospitals enrolled in this study did not bias the selection of Hologic DXA.

    Conclusions: Neighboring institutions should consider sharing access to Hologic DXA equipment to ensure the use of uniform reference values. GE BMD reference values for Japanese children should be established.

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  • Satoshi Mizutani, Nobuhiko Taniai, Hiroyasu Furuki, Mio Shioda, Junji ...
    Article ID: JNMS.2021_88-408
    Published: 2020
    [Advance publication] Released: August 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background

    Pancreatic body and tail cancer easily invades the retroperitoneal tissue, including the transverse mesocolon. It is difficult to ensure a dissected peripancreatic margin using standard distal pancreatectomy for advanced pancreatic body and tail cancer.

    Thus, we developed a novel surgical procedure to ensure dissection of the peripancreatic margin. This involved performing dissection deeper than the fusion fascia of Toldt and further extensive en bloc resection of the root of the transverse mesocolon. We performed distal pancreatectomy with transverse mesocolon resection (DP-TCR) using the mesenteric approach and achieved good outcomes.

    Methods

    There are two main considerations regarding the surgical procedure using the mesenteric approach: 1) dissection deeper than the fusion fascia of Toldt (securing the vertical margin) and 2) modular resection of the pancreatic body and tail, with the root of the transverse mesocolon and adjacent organs in a horizontal direction (ensuring the caudal margin).

    Results

    From 2017 to 2019, we performed DP-TCR using the mesenteric approach for six patients with advanced pancreatic body and tail cancer. Histopathological radical surgery was possible in all patients who underwent DP-TCR. No perioperative complications of grade IIIa or above in the Clavien–Dindo classification were observed in any patients.

    Conclusions

    We believe that DP-TCR is useful as a radical surgery for advanced pancreatic body and tail cancer with extrapancreatic invasions.

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  • Shan Jin, Iwao Sugitani
    Article ID: JNMS.2021_88-409
    Published: 2020
    [Advance publication] Released: August 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: This study aimed to induce an animal model for TSH suppression therapy after total thyroidectomy in rats.

    Methods: A total of 60 Wistar rats were randomly divided into 6 groups, including sham-operated group (SO group),total thyroidectomy group (TD group), L-T4 treatment I group (TS-I group), II group (TS-II group), III group (TS-Ⅲ group), and IV group (TS-Ⅳ group), in which the rats were accordingly treated with 1.4, 1.6, 1.8, and 2.0 μg/100g body weight after total thyroidectomy.

    Results: HE staining in the TD group and all L-T4 treated rats showed that the resected tissue was normal thyroid gland in rats, and no residual thyroid tissue was found in the neck tissue of the cross-section of thyroid gland. The serum levels of T3 in the TS-II group were not significantly different from those in the SO group, whereas the serum level of T4 was slightly higher than that in the SO group, and the serum level of TSH was slightly lower than that in the SO group.

    Conclusions: Rats subcutaneously injected with L-T4 at a dose of 1.6 μg/100g body weight for 15 days after total thyroidectomy could induce an animal model for TSH suppression therapy. It may be used as an animal model for TSH suppression therapy.

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  • Azusa Ogita, Shin-ichi Ansai
    Article ID: JNMS.2020_87-609
    Published: 2020
    [Advance publication] Released: August 01, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Herein, we report a case of solitary infantile myofibroma (IM) on the back of a newborn with partial CD34-positivity in neoplastic cells. On ultrasonographic examination, the tumor appeared as a multilocular mass with a hypoechoic center surrounded by an isoechoic rim. Histopathologically, the lesion was composed of tightly packed, uniform, small, round cells with pale, oval nuclei, CD34-positivity, and richly cellular, interlacing fascicles of spindle cells, with features of myofibroblasts with α-smooth muscle actin (α-SMA) positivity. We speculate that neoplastic cells in most cases of IM differentiate towards myofibroblasts. However, in rare instances, their differentiation is more primitive and they can express CD34 with or withoutα-SMA expression.

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  • Yuji Tomori, Mitsuhiko Nanno, Sonoki Kentrao, Tokifumi Majima
    Article ID: JNMS.2020_88-206
    Published: 2020
    [Advance publication] Released: August 01, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Thumb opposition is an essential movement for daily use of the hand, including precise pinch or grasping as well as fine and complicated hand movement. Although previous studies have reported several donor tendons for opponensplasty, opponensplasty using palmaris longus, Camitz opponensplasty, have been utilized in patients who have loss of opposition function due to long-standing carpal tunnel syndrome, because the procedure involves a simple and useful tendon transfer without causing functional deficits. To obtain enough length to transfer the tendon to the metacarpophalangeal joint of the thumb, the PL tendon should be obtained along with the palmar aponeurosis. However, the palmar aponeurosis is not always available for the opponensplasty, as it occasionally appears thin and is not sufficient for the elongation of the palmaris longus. The extended skin incision over the palm causes painful scar formation or postoperative residual pain. This procedure restores the palmar abduction function of the thumb, but not the opposition function. In the present article, we present the modified Camitz opponensplasty using half split of palmaris longus, which has enough length to anchor to the insertion of the adductor pollicis at the metacarpophalangeal joint of the thumb.

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  • Rei Ogawa, Teruyuki Dohi, Mamiko Tosa, Masayo Aoki, Satoshi Akaishi
    Article ID: JNMS.2021_88-106
    Published: 2020
    [Advance publication] Released: August 01, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    In 2006, we established a scar/keloid-specialized institution in the Department of Plastic, Reconstructive, and Aesthetic Surgery at Nippon Medical School (NMS) in Tokyo, Japan. In the ensuing 15 years, we treated approximately 2000 new scar/keloid patients annually. This extensive experience has greatly improved the efficacy of the treatments we offer. Therefore, we discuss here the latest NMS protocol for preventing and treating keloids and hypertrophic scars. While this protocol was optimized for Japanese patients, our experiences with a growing body of international patients suggest that it is also effective in other ethnicities. The extensive evidence-based experience underlying the NMS protocol suggests that it may be suitable as the foundation of a standard international prevention/treatment algorithm for pathological scars.

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  • Shintaro Kanaka, Youichi Kawano, Shigeki Yokomuro, Fumihiko Ando, Nori ...
    Article ID: JNMS.2021_88-306
    Published: 2020
    [Advance publication] Released: August 01, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Immunoglobulin G4 (IgG4) -related disease (IgG4-RD) is a recently characterized entity in which lymphocytes and plasma cells infiltrate various anatomical sites. IgG4-hepatopathy, which is the manifestation of IgG4-RD, is a broader term covering various patterns of liver injury. The clinical course including the malignant potential of IgG4-RD remains unclear. Here we report the first case of secondary hemochromatosis and hepatocellular carcinoma (HCC) developed from IgG4-hepatopathy. A 67-year-old man was admitted to our hospital due to deteriorated glucose tolerance. Blood test results showed hypergammaglobulinemia, especially IgG4. He was readmitted 2 months later with dyspnea due to lung disease and pleural effusion, with elevated transaminase levels. He underwent liver and lung biopsies and was diagnosed with IgG4-RD, and received steroid therapy, which improved his serum IgG4 levels and imaging abnormalities. A follow-up computed tomography (CT) scan conducted 38 months later demonstrated a 50-mm-diameter tumor segments 7 and 8 of the liver. The resected specimen revealed HCC and abundant siderosis in the background liver, leading to a diagnosis of hemochromatosis. IgG4-positive cells were scarce, probably due to corticosteroid therapy. In the present case, IgG4-RD was well controlled with prednisolone (PSL) and immunosuppressive agent, and chronic hepatitis was not so severe, even though the patient subsequently developed HCC. However, extensive siderosis consistent with hemochromatosis was unexpectedly noted. It is suggested that secondary hemochromatosis and HCC developed during IgG4-RD with hepatopathy. Here we report the present case because it contributes to our understanding of IgG4-RD.

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  • Naoto Matsuda, Syun Iida, Yukitomo Ogino, Noboru Saito, Masahiro Yasut ...
    Article ID: JNMS.2021_88-307
    Published: 2020
    [Advance publication] Released: August 01, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    We describe a case of fever of unknown origin (FUO), renal failure, and pancytopenia. Initially, lymph proliferative disorder was suspected; therefore, bone marrow biopsy and 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) were performed. Bronchoscopy and lung biopsy were performed because of abnormal FDG uptake in both lung fields. Taken together with the laboratory and histological results, sarcoidosis with bone marrow invasion was confirmed. The patient was discharged following favorable response to corticosteroid therapy. Sarcoidosis may present as FUO without typical specific presentations in the skin or lung. Combined 18F-FDP PET/CT helped identify the biopsy site and confirmed sarcoidosis diagnosis.

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  • Keiko Mashimo, Youkichi Ohno
    Article ID: JNMS.2021_88-501
    Published: 2020
    [Advance publication] Released: August 01, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: There have been no comprehensive investigations that examined the alteration of heart gene expression due to ethanol exposure. Therefore, we attempted to obtain gene expression from cultured neonatal rat cardiomyocytes exposed to ethanol (0, 10, 50, 100 mM) for 24 h.

    Methods: The total RNA extract of beating cardiomyocytes was evaluated using DNA microarray, and fold changes (FCs) of differential gene expression of ethanol-exposed cardiomyocytes were analyzed against the control using Ingenuity Pathway Analysis (IPA) software.

    Results: The 1,394 genes with |FC| ≥ 1.8 were uploaded to IPA. IPA predicted 23 canonical pathways working in the ethanol groups. Three canonical pathways related to ethanol degradation, "Ethanol Degradation IV", "Oxidative Ethanol Degradation III", and "Ethanol Degradation II", were inhibited in the ethanol groups. IPA predicted "ethanol" as an upregulated upstream regulator of the network having 22 downstream members for only the 100 mM ethanol group, 3 members, NTRK2, TGFB3, and TLR8, being activated in all groups. Certain cellular functions were predicted to alter dose-dependently; "Myocarditis" was dose-dependently inhibited, whereas "Cell death of heart cells" was dose-dependently activated. Several functions were inhibited only in 50 mM ethanol; "Failure of heart" was enhanced only in 50 mM ethanol. Certain functions were activated only in 100 mM ethanol. "Cardiac fibrosis" was not predicted in any of ethanol groups.

    Conclusions: IPA predicted ethanol-induced activation or inhibition of canonical pathways and functions of cardiomyocytes depending on the concentrations of ethanol, and 3 networks related to heart functions of cardiomyocytes exposed to 3 concentrations of ethanol.

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  • Toru Igarashi, Sachiyo Takeda, Tsutomu Igarashi, Hidehiko Narazaki, Ya ...
    Article ID: JNMS.2021_88-502
    Published: 2020
    [Advance publication] Released: August 01, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: In preparation for the 2020 Tokyo Olympic/Paralympic Games, the Japanese government assessed the risks of infectious disease outbreaks and determined necessary preparations. This present study reviews efforts made during a previous measles epidemic and describes the roles of hospitals.

    Methods: This descriptive study investigated the records of 198 children with measles. Each child was treated at a general hospital January 1997 and February 1998. The study also examined the actions of pediatricians during and after the measles outbreak in the community.

    Results: Of the 198 children, 145 (73%) were hospitalized. The measles vaccination rate in the previous year was approximately 75%. Of the patients examined, 53% were below two years of age. The mean age was two years and nine months. Pneumonia and gastroenteritis accounted for 46% and 30% of the complications, respectively. Issues requiring attention included the number of hospital beds located in a negative pressure room or a private room with a window, obtaining gamma globulin preparation with a high measles antibody titer, increased vaccination opportunities, and extended working hours for doctors.

    Conclusions: Measles outbreaks are possible in Japan as a result of visitors from abroad. Items to mitigate an outbreak were identified as maintenance of high vaccination rates, readily available information regarding the location of negative pressure hospital rooms, the status of measles development, and finally medical staffing issues. There is a continued risk of measles outbreaks occurring in infants and individuals who do not have a measles antibody titer.

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  • Akihito Yamamoto, Seiryu Kamoi, Mariko Ikeda, Takashi Yamada, Koichi Y ...
    Article ID: JNMS.2021_88-503
    Published: 2020
    [Advance publication] Released: August 01, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background

    Radical hysterectomy (RH) is a type of radical surgery performed for cervical cancer. Urinary dysfunction due to RH exacerbates the postoperative quality of life of cervical cancer patients. The nerve-sparing RH (NSRH) technique has been used as an effective measure to conserve urinary function. However, few reports have been published on the long-term prognosis. This study described performance of our nerve-sparing technique and the long-term prognosis of patients.

    Methods

    Sixty-one patients underwent radical hysterectomy in a 5-year period during which the nerve-sparing technique was introduced; of these, 31 patients underwent NSRH and 30 underwent conventional RH. We retrospectively examined the medical records and compared postoperative urinary function and treatment outcome between the 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 2,456.3 days (range, 48–4,213 days). Investigations on curability revealed no significant difference between the two groups in local recurrence and 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

    Surgical procedures for NSRH significantly improved postoperative urinary function without deteriorating local recurrence rates and long-term prognosis.

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  • Koji Ueharu, Takeshi Asano, Ryohei Fukunaga, Ryosuke Matsui, Keishi Yo ...
    Article ID: JNMS.2020_87-606
    Published: 2020
    [Advance publication] Released: June 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Kawasaki disease is a systemic vasculitis of unknown etiology and is known to be associated with various digestive disorders, though only a few cases of intussusception associated with Kawasaki disease have been reported. The case of a 3-year-old boy with intussusception followed by Kawasaki disease is reported. The patient was admitted to our hospital due to severe abdominal pain. Because the target sign was seen on ultrasonography, intussusception was diagnosed, and hydrostatic reduction was performed. On the second day after admission, he developed a high-grade fever (38 oC) and an irregular rash on the whole body. On the fourth day after admission, his high-grade fever continued, and bilateral non-exudative conjunctivitis, erythema of the lips and oral mucosa, strawberry tongue, indurated edema of the dorsum of his hands and feet, and a diffuse erythema of his palms and soles appeared, and he was finally diagnosed as having Kawasaki disease. He was treated with intravenous immune globulin 2 g/kg, aspirin 30 mg/kg/day, and prednisolone 2 mg/kg/day. The high-grade fever, as well as the other clinical symptoms, resolved immediately after the start of treatment. There was no relapse of Kawasaki disease symptoms after initial treatment, and periungual desquamation was observed on the tenth day after admission. He was discharged on the 15th day and showed no abnormalities, such as coronary dilatation, three months after the onset of the symptoms of Kawasaki disease. Age distribution (≥ 3 years old vs < 3years old) between cases with intussusception and Kawasaki disease was clearly older than that with intussusception only. In addition, location of intussusception with Kawasaki disease was mainly colonic, not ileocolic. If intussusception precedes the appearance of the characteristic clinical symptoms of Kawasaki disease, the diagnosis of Kawasaki disease may be delayed. We must be aware of the diagnosis of Kawasaki disease in cases of intussusception in over three years old and colonic location of intussusception.

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  • Kumi Chubachi, Junko Umihara, Akiko Yoshikawa, Shinji Nakamichi, Susum ...
    Article ID: JNMS.2021_88-401
    Published: 2020
    [Advance publication] Released: June 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: The participation of patients in the decision-making process related to their treatment is strongly recommended. This study was conducted to develop and evaluate a support tool that can help patients make decisions related to their own treatment.

    Methods: Twenty cancer patients who were hospitalized for first line treatment were enrolled on the study. Before hospitalization, a 'Check sheet on treatment selection', which contained 14 questions, was distributed to patients and/or their families. After hospitalization, the attending physician explained the treatment while referring to the written check sheet. Also, at the time of discharge, the patients's responses to the 'Questionnaire on check sheet and treatment selection' were collected in order to evaluate the utility of the check sheet. Finally, the 'Questionnaire of the check sheet' was handed to the attending physician to evaluate.

    Results: Of the fourteen patients who responded to the questionnaire, all indicated that the check sheets were helpful for decision-making, and that using the sheets empowered them to ask their doctors questions. Only one person felt uncomfortable with compiling the check sheet.

    Physicians stated that the check sheet facilitated patient decision-making and improved communication with patients. However, there was an opinion that this activity increased the administrative burden of medical professionals.

    Conclusion:

    Almost all patients stated that the check sheet used in this study was useful as a decision support tool, and also facilitated the communication between doctors and patients. Before incorporation into general clinical practice, this increased benefit should be weighed against the potential extra administrative workload imposed on clinicians.

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  • Hidehiko Narazaki, Makoto Watanabe, Makoto Migita, Ryuhei Kurashina, Y ...
    Article ID: JNMS.2021_88-403
    Published: 2020
    [Advance publication] Released: June 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: There has been significant progress in reducing perinatal mortality in Japan. However, due to changes in social conditions, the total fertility rate and the number of births are decreasing, whereas the number of low birth weight infants is increasing along with the number of newborn babies that require intensive care. Further, although the number of high-level perinatal medical centers has increased, so has that of infants who need long-term hospitalization. Conversely, the number of regular obstetric facilities has decreased, thus resulting in insufficient beds for neonatal care. To fill this gap, we established a neonatal intensive care unit (NICU) at our hospital. This study aimed to evaluate our new type by comparing the data from ours with that from other facilities.

    Methods: The other facilities assessed were two high-level NICU facilities and two regular obstetric facilities. Data, including sex, gestational age, birth weight, Apgar scores at 1 and 5 min, delivery method, and presence of breathing disorders, were extracted from medical records.

    Results: The birth weight and gestational age distributions were significantly different in the institutions, except in one facility without a NICU. The new NICU saw more infants with low birth weight and respiratory disorders than the regular obstetric facilities.

    Conclusion: The comparison of birth weight and gestational age distributions, cases of respiratory disorders, and delivery methods indicate that our new NICU is positioned as an intermediate facility between a high-level NICU and a regular obstetrics facility.

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  • Shoji Yokobori, Ken Saito, Kazuma Sasaki, Takahiro Kanaya, Yu Fujiki, ...
    Article ID: JNMS.2021_88-404
    Published: 2020
    [Advance publication] Released: June 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Due to aging of the Japanese population, traumatic brain injuries (TBI) in elderly individuals have increased. However, the effectiveness and prognosis of intensive treatment in geriatric TBI have not yet been determined. Thus, we analyzed the prognostic factors of intensive and aggressive treatments using nationwide data from Japan Neurotrauma Data Bank (JNTDB) projects.

    Methods: We analyzed 1,879 geriatric TBI cases (≥65 years old) registered in four JNTDB projects, Project 1998 (P1998) to Project 2015 (P2015). Clinical features, aggressive treatment usage, and 6-month outcomes on the Glasgow Outcome Scale (GOS) were compared among study projects. Logistic regression was performed to clarify prognostic factors in aggressively-treated patients.

    Results: The percentage of geriatric TBI cases significantly increased across time (P1998: 30.1%, Project 2004 (P2004) : 34.6%, Project 2009 (P2009) : 43.9%, P2015: 53.6%, p<0.0001). Aggressive treatment usage also significantly increased, from 67.0% in P1998 to 69.3% in P2015 (p<0.0001). Less invasive methods, such as trepanation and normothermic targeted temperature management, were more often chosen for geriatric patients. These efforts resulted in a significant decrease in the 6-month mortality rate, from 76.2% in P1998 to 63.1% in P2015 (p=0.0003), although the percentage of severely disabled patients increased, from 8.9% in P1998 to 11.1% in P2015 (p = 0.0003). Intraventricular hemorrhage was the most unfavorable prognostic factor for the 6-month outcome (OR 3.79, 95% CI 1.78–8.06, p<0.0001).

    Conclusions: Less invasive treatments reduce mortality in geriatric TBI but do not improve functional outcomes. The patients' age does not seem to be the strongest prognostic factor; thus, physicians should not adhere to only age.

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  • Takeshi Asano
    Article ID: JNMS.2020_87-508
    Published: 2020
    [Advance publication] Released: May 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Effective leukemia treatment is seriously hampered by drug resistance. The possible roles of epigenetic mechanisms have recently been considered in cancer drug resistance. With conventional anti-cancer drugs, including alkylating drugs, anti-metabolite drugs, topoisomerase inhibitors, and microtubule inhibitors, which have been available for half a century, the drug resistance often occurs due to decreased expression of target enzymes, with increased expression of drug export pumps. The alterations of target gene expression and increased export pump function might be caused by epigenetic changes, such as changes of methylation status, as well as changes of histone acetylation status. In addition, newly developed anti-cancer drugs, including small molecule drugs such as kinase inhibitors, antibody drugs, and immune modulatory drugs, also showed development of drug resistance within a year, although these drugs show significant efficacy in conventional anti-cancer drug-resistant patients. The resistant cells showed increased expression of bypass pathways, activation of downstream cascades, decreased expression of antigens of tumor cells, increased DNA repair activity, and increased expression of drug export pumps, also suggesting epigenetic changes. In this paper, drug resistance to cancer therapy and the possible roles of epigenetic mechanisms are reviewed.

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  • Miki Miyazawa, Takeshi Shimakawa, Shinichi Asaka, Kentaro Yamaguchi, M ...
    Article ID: JNMS.2020_87-509
    Published: 2020
    [Advance publication] Released: May 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    In recent times, the diagnosis and treatment of superficial laryngopharyngeal cancers has been receiving a lot of attention. Here, we present a case of superficial hypopharyngeal cancer and superficial esophageal cancer for which endoscopic laryngo-pharyngeal surgery (ELPS) and endoscopic submucosal dissection (ESD) were performed simultaneously. The patient was a 67-year-old male. During his follow-up for distal gastrectomy performed earlier for stomach cancer, an upper gastrointestinal endoscopy revealed three primary cancers: superficial hypopharyngeal cancer, superficial esophageal cancer, and esophagogastric junction cancer. Total resection of the remnant stomach was performed followed by hypopharyngeal ELPS combined with esophageal ESD. He developed aspiration pneumonia after the surgery; however, he recovered and was discharged on the 16th day. Thus, safe and effective endoscopic therapy can be performed even for double superficial cancers of the laryngopharynx and esophagus.

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  • Kohsuke Terada, Yuichiro Sumi, Sae Aratani, Akio Hirama, Yukinao Sakai
    Article ID: JNMS.2020_87-511
    Published: 2020
    [Advance publication] Released: May 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    In patients undergoing peritoneal dialysis (PD), peritonitis is one of the most common complications, and causes PD catheter removal, permanent transfer to hemodialysis, and potentially death. Therefore, the prediction and prevention of PD-related peritonitis are extremely important. In 2016, the International Society for Peritoneal Dialysis published guidelines for peritonitis in patients undergoing PD; these guidelines cover most cases of PD-related peritonitis caused by various bacteria. Furthermore, the guidelines clearly propose the indications for catheter removal. However, difficulties often arise when deciding on the best time for catheter removal. Peritonitis with the identification of multiple enteric organisms from a culture of dialysis effluent may be caused by intra-abdominal pathology, and if a patient with peritonitis has such pathology, the mortality rate is high, and the catheter removal is considered in that case. In this report, we describe a case in which, during antibiotic therapy for PD-related peritonitis due to Enterococcus faecalis alone, the patient suffered another occurrence of peritonitis due to newly revealed Gram-negative rod-like Pseudomonas aeruginosa. He required catheter removal due to the peritonitis being suspected of relapsing. Although so further investigations are required, it is possible that early catheter removal is effective in cases in which another organism is newly detected during antibiotic therapy for PD-related peritonitis caused by a different responsible organism not meeting the definition of refractory peritonitis.

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  • Eri Kuramochi, Kazuya Mae, Yuuka Ohtomo, Reina Kamada, Hanako Sugano-T ...
    Article ID: JNMS.2021_88-103
    Published: 2020
    [Advance publication] Released: May 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Since 2002, the Department of Pediatrics of Nippon Medical School Chiba Hokusoh Hospital has offered educational activities for children with short stature. We analyzed outcomes of growth hormone (GH) treatment for children with short stature treated at our hospital, particularly outcomes after the growth spurt.

    Methods: We analyzed data from children aged 0 to 17 years who were treated with recombinant GH during the period from 2000 through 2016 and were followed for at least 2 years after the start of treatment.

    Results: Among children with short stature, 85 had GH deficiency, 5 had Turner syndrome, 9 were small for gestational age, and 1 had Noonan syndrome. The outcomes of GH treatment was similar to those previously reported in Japan. Children with GH deficiency who started GH treatment before the growth spurt exhibited marked height catch-up until the second year, but the effect decreased after 3 years. The effect of treatment for GH deficiency that was started after the growth spurt continued for 4 to 5 years after the start of treatment.

    Conclusions: Improvement in height standard deviation score was similar when treatment was started before and after the growth spurt.

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  • Fumitaka Okajima, Hitoshi Sugihara, Naoya Emoto
    Article ID: JNMS.2021_88-205
    Published: 2020
    [Advance publication] Released: May 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background

    Combination therapy with an alpha-glucosidase inhibitor or glinide plus a dipeptidyl peptidase-4 inhibitor is thought to be effective for glycemic control because of its effects on postprandial hyperglycemia. However, no studies have directly compared the efficacy and safety of these two combination therapies.

    Methods

    Eighteen patients with type 2 diabetes were studied. All had diabetes not adequately controlled with diet and exercise therapy and an HbA1c level of ≥7.5%; none were receiving any medication for diabetes. The patients were randomized to either miglitol- or repaglinide-based combination therapy with alogliptin. Patients received miglitol or repaglinide monotherapy for 3 months (the miglitol and repaglinide groups, respectively), after which alogliptin was added to each group as combination therapy for 3 months. A meal tolerance test (MTT) was performed before the start of treatment and at the end of monotherapy and combination therapy.

    Results

    During the study period, decreases in HbA1c and glycated albumin were significantly greater in the repaglinide group than in the miglitol group; however, there was no significant difference between treatment groups at the end of the study. At the end of monotherapy, insulin secretion relative to glucose elevation (ISG0-30: area under the curve of insulin from 0 to 30 min during MTT [AUC0-30 of IRI]/AUC0-30 of plasma glucose) was significantly increased only in the repaglinide group; ISG0-30 did not significantly increase in either group after the addition of alogliptin.

    Conclusions

    The addition of alogliptin to repaglinide monotherapy did not cause glucose-independent inappropriate insulin secretion and did not appear to increase the incidence of hypoglycemia.

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  • Masato Yanagi, Go Kimura, Tetsuro Sekine, Hayato Takeda, Jun Akatsuka, ...
    Article ID: JNMS.2021_88-302
    Published: 2020
    [Advance publication] Released: May 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: While high body mass index (BMI) and visceral obesity are reportedly associated with a prolonged duration of laparoscopic radical nephrectomy (LRN) via the transperitoneal approach, factors that might prolong the retroperitoneal approach remain unknown. We therefore investigated factors associated with prolonged LRN using a retroperitoneal approach applied by non-expert surgeons.

    Methods: We defined surgeons who were not certified to perform laparoscopic surgery by the Japanese Society of Endourology as non-experts. We retrospectively reviewed the medical records of 59 consecutive patients with renal cell carcinoma treated with LRN using the retroperitoneal approach by non-experts at our hospital between 2014 and 2019. Relationships between surgical duration and age, sex, body mass index, visceral fat area (VFA) and subcutaneous fat area (SFA), laterality and location of the tumor, length of major tumor axis (tumor length), clinical T stage, ipsilateral adrenalectomy and specimen weight were analyzed using Spearman rank correlation coefficients.

    Results: The surgical duration positively correlated with ipsilateral adrenalectomy (rs = 0.3162, p = 0.0147) and specimen weight (rs = 0.3103, p = 0.0168), but not with BMI (rs = 0.2016, p = 0.1257) or VFA (rs = 0.0185, p = 0.8894).

    Conclusions: Factors associated with prolonged LRN via the retroperitoneal approach implemented by non-expert surgeons are ipsilateral adrenalectomy and specimen weight.

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  • K Asai, M Murai, A Shirakabe, M Kamiya, S Noma, N Sato, K Mizuno, W Sh ...
    Article ID: JNMS.2021_88-303
    Published: 2020
    [Advance publication] Released: May 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Although heart failure (HF) with preserved ejection fraction (HFpEF) is more common in postmenopausal women than in men, the effect of sex hormones on cardiac diastolic function remains unclear. We examined the effect of gonadectomy with or without an angiotensin receptor blocker, olmesartan (Olm), in an isoproterenol (ISO) -induced mouse model of left ventricular hypertrophy (LVH) and cardiac diastolic dysfunction. Methods: ISO or ISO with Olm were administered for 28 days in sham-operated male and female, castrated (CAS), and ovariectomized (OVX) mice. The LV ejection fraction (EF) and E/A ratio were analyzed using echocardiography, and the LV and lung weight corrected by tibial length were determined as indices of LVH and lung congestion, respectively.

    Results: On echocardiography, the systolic function did not differ between the four groups. The LV/tibial length (TL) and Lung/TL significantly increased in all groups. The LV/TL was lower in castrated-ISO vs. Male-Sham-ISO, but did not differ between Female-Sham-ISO and OVX-ISO. However, the Lung/TL of OVX-ISO was greater than that of Female-Sham-ISO. Olm prevented LV hypertrophy in all groups. The decreased E/A and increased lung weight were improved by Olm in Male-Sham and OVX-ISO, but not in the others.

    Conclusion: These gender differences suggest that sex hormones play a pivotal role in modulating cardiac hypertrophy and diastolic dysfunction induced by chronic beta-adrenoceptor stimulation, thereby affecting the therapeutic potential of angiotensin receptor blockade.

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  • Hiroaki Kishikawa, Norihito Suzuki, Yasutomo Suzuki, Tsutomu Hamasaki, ...
    Article ID: JNMS.2021_88-304
    Published: 2020
    [Advance publication] Released: May 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Robot-assisted surgery and pure laparoscopic surgery are available for minimally invasive radical prostatectomy (MIRP). The differences in anesthetic management between the two MIRPs under combined general and epidural anesthesia (CGEA) remain unknown. This study therefore aimed to determine the effects of robot-assisted surgery on anesthetic and perioperative management for MIRP under CGEA.

    Methods: A retrospective observational study was performed by obtaining data from the patients' electronic medical records. Demographic data, intraoperative parameters, postoperative complications, and hospital stays after the MIRPs were compared between patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP) and those with pure laparoscopic radical prostatectomy (LRP).

    Results: There were no differences in the patients' background data between the 102 who underwent RALP and 112 who underwent LRP. Anesthesia and surgical times were shorter in the RALP group than in the LRP group. Consumption of anesthetics, including intravenous opioids, and epidural ropivacaine, was less in the RALP group. Although the estimated blood loss and volume of colloid infusion were lower in the RALP group, the volume of crystalloid infusion was larger. Intraoperative allogeneic transfusion was not required in either group. There were no differences in incidents of postoperative cardiopulmonary complications or postoperative nausea and vomiting (PONV) in either MIRP group. Hospital stays after the procedure were shorter in the RALP group.

    Conclusions: Robot-assisted surgery required varied consumption of anesthetics and infusion management during MIRP under GCEA. It also shortened the postoperative hospital stay without increasing the rates of postoperative complications.

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  • Kazuyuki Kubo, Hiroyuki Takei, Atsumori Hamahata
    Article ID: JNMS.2021_88-204
    Published: 2020
    [Advance publication] Released: April 30, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: In cases of mastectomy for locally advanced breast cancer (LABC), surgical skin flap reconstruction is sometimes required to cover large skin defects. In this study of patients with LABC, the patient group that required local flap reconstruction after mastectomy and the patient group that underwent mastectomy alone were compared to evaluate the efficacy of local, cutaneous (rhomboid) flap reconstruction after mastectomy.

    Methods: Sixty-eight patients with LABC who underwent mastectomy were reviewed retrospectively. Fourteen patients underwent local (rhomboid) flap reconstruction after mastectomy (local flap group) and 54 patients underwent direct closure after mastectomy (direct closure group). A pinch test was performed to determine the closure method. Data regarding the operation and post-operative complications and quality of life (QOL) were compared between both groups.

    Results: It was possible to close defects in the local flap group that were significantly larger than those in the direct closure group (p=0.0002), and there were no significant differences in post-operative complications between the groups. Although the operative duration was significantly longer in the local flap group than in the direct closure group (p=0.016), the average difference was only 25 minutes. There were no significant differences in factors pertaining to post-operative QOL.

    Conclusions: Rhomboid flap reconstruction is effective for covering large defects after mastectomy in patients with LABC.

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  • Tadashi Higuchi, Fumio Yamaguchi, Takayuki Asakura, Daizo Yoshida, Yum ...
    Article ID: JNMS.2020_87-601
    Published: 2020
    [Advance publication] Released: March 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background:

    5-Aminolevulinic Acid (5-ALA) Photodiagnosis (PD) is an effective method to detect residual tumors during glioma surgery. However, the strength of fluorescence differs in every case even in the most malignant glioma such as glioblastoma. Also, false-negative fluorescence may result in tumor residue. We investigated the effect of ultrasound on the intracellular level of protoporphyrin IX (PpIX) and the expression level of ATP-binding cassette transporter 2 (ABCG2), which is thought to act as a membrane efflux pump of PpIX from cytosol.

    Methods:

    The malignant glioma established cell line, SNB19, U87MG and T98G were used for in vitro experiments. Ultrasound (1MHz, 3W/cm2, Duty cycle 10%) was irradiated on the cultured cells after administration of 5-ALA. The morphological changes of tumor cells were observed. The PpIX levels and the expression of ABCG2 were evaluated.

    Results:

    The glioma tumor cells showed transient morphological changes and attachment to the culture dish, while most cells survived and were restored to their original morphology within 6 hours. The PpIX expression levels increased in glioma cells after ultrasound irradiation, earlier and higher than 5-ALA alone. Concurrently the expressions of ABCG2, that increased after 5-ALA administration, were relatively reduced in ultrasound irradiated glioma cells.

    Conclusions:

    The ultrasound irradiation of the malignant gliomas contributes to the stronger 5-ALA induced fluorescence by elevating intracellular PpIX levels. The suppression of ABCG2 expression by ultrasound may be one of the factors which contributes to the PpIX accumulation in glioma cells.

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  • Yasuyuki Kitagawa, Yoshihiro Sudo, Ryu Tsunoda, Mitsuhiko Nanno, Sator ...
    Article ID: JNMS.2020_87-602
    Published: 2020
    [Advance publication] Released: March 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Angioleiomyomas are usually small and relatively rare painful soft tissue tumors, and are usually less than 2 cm in diameter. Magnetic resonance (MR) imaging features of typical angioleiomyomas are not well understood, and their association with histologic subtypes is not clear. In the present study, MR images of average sized angioleiomyomas were compared with regard to specific histologic subtypes.

    Methods: We performed a retrospective review of medical records, MR imaging data, and histologic specimens of 18 consecutive patients with angioleiomyomas that were extirpated at our hospital between January 2006 and December 2013.

    Results: Most of the lesions showed homogenous iso-signal intensities compared to skeletal muscle on T1-weighted images; however, on T2-weighted images, solid and venous types showed heterogenous and iso- to slightly high-signal intensity, while the cavernous type showed high-signal intensity. Most of the lesions had a low-signal intensity rim, and two thirds of them had adjacent vessels.

    Conclusions: Our results suggested that MR findings of angioleiomyoma vary depending on histologic subtypes. T2-weighted images of solid and venous types of angioleiomyoma show specific MR findings which allow for differentiation from other soft tissue tumors such as soft tissue sarcomas. These mostly show iso- to slightly high-signal intensity compared to skeletal muscle, while the cavernous type show non-specific findings. Thus, solid and venous types of angioleiomyoma could be diagnosed preoperatively via clinical findings and MR imaging.

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  • Hirohito Takeuchi, Yoshihiro Furuichi, Yu Yoshimasu, Yoshitaka Kasai, ...
    Article ID: JNMS.2020_87-603
    Published: 2020
    [Advance publication] Released: March 31, 2020
    JOURNALS FREE ACCESS ADVANCE PUBLICATION

    Background: Thrombopoietin (TPO) receptor agonist, Lusutrombopag, is recently released to treat thrombocytopenia in chronic liver disease (CLD). However, its effectiveness remains to be unclear. The purpose of this study was to clarify the efficacy of Lusutrombopag and identify the predictors associated with platelet count increase.

    Methods: Eighty CLD patients with thrombocytopenia were enrolled. The primary endpoint was the Lusutrombopag effect, which is the proportion of cases satisfying following; the platelet increase was enough (with an increase of greater than 1.0 × 104/μL from at baseline) and platelet transfusion was not required. The secondary endpoints were the response rate (which showed an increase of greater than 1.0 × 104/μL from at baseline), independent predictors of increased platelets, and the superiority of Lusutrombopag over platelet transfusion.

    Results: The primary endpoint was 93.8% (75 of 80 patients). The response rate was 96.2% (77 of 80). Factors indicative of renal function (BUN, creatinine, eGFR) significantly and negatively correlated with increase in platelets (p = 0.033, 0.049, 0.0014, respectively), and were also identified as independent predictors by multiple regression analysis (p = 0.049, 0.0023, 0.0016, respectively). The median increase in platelet count after Lusutrombopag was significantly higher than that after platelet transfusion (41000 vs. 12000 /μL, p = 0.015).

    Conclusion: This study revealed that Lusutrombopag was more sufficiently effective in CLD patients compared with platelet transfusion and that renal function is independent predictor of increase. Factors indicative of renal function significantly and negatively correlated with increase in platelets.

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