Summary: Autoimmune hepatitis (AIH) is a liver disease of unknown etiology, characterized by the presence of autoantibodies, increased immunoglobulin G levels in blood, chronic/persistent liver disorder, and favorable response to immunosuppressive therapy. Although the diagnosis of typical AIH cases has become easier, the absence of disease-specific markers poses challenges when diagnosing atypical cases, such as acute-onset AIH or AIH overlapping with drug-induced liver injury, metabolic liver disease, or other autoimmune disorders. Corticosteroids remain the first-line treatment for AIH; however, azathioprine is now covered by health insurance in Japan and can be used to treat AIH. Expanding treatment options is desirable, particularly for elderly patients and refractory cases. This review aims to provide an overview of the diagnosis, treatment, and prognosis of AIH while introducing historical perspectives and current emerging topics. The prevalence of AIH is increasing in Japan and other countries. Although the prognosis is generally favorable, given the possibility of long-term survival, periodic cancer screenings are advisable owing to the risk of carcinogenesis.

Summary: Objectives: Numerous clinical trials have proven that hyperbaric oxygen therapy (HBOT) is an effective adjunctive treatment for inflammatory bowel disease (IBD). The present study evaluated the effect of HBOT in patients with postoperative ulcerative colitis (UC).

Methods: This retrospective study examined the effects of HBOT on short-term postoperative outcomes in patients with UC. This study included 21 patients with postoperative UC between January 2013 and December 2023. Of these, six patients received HBOT; the previous indication for HBOT was postoperative ileus. The nutritional status, inflammatory findings, and disease severity scores were evaluated during the one-month post-operative period.

Results: In the univariate analysis, the mean age was higher in the non-HBOT group than in the HBOT group (54.3 vs. 64.9 years old, p=0.0461), although the operative details and severity did not differ markedly. The usefulness of the Controlling Nutritional Status (CONUT) score as a nutritional screening and predictive tool has been demonstrated for various inflammatory and neoplastic diseases, including UC. The CONUT score was inversely correlated with Onodera’s prognostic nutritional index and positively correlated with the platelet count, C-reactive protein level, and erythrocyte sedimentation rate. In addition, the HBOT group had a lower CONUT score 1 month after surgery than the non-HBOT group (2.0 vs. 4.4, p= 0.0190).

Conclusions: Postoperative UC patients who received HBOT had better CONUT scores at 1 month compared to those who did not.

Summary: Background and Aims: Endoscopic ultrasound (EUS) can evaluate morphological changes in various pancreatic diseases. We aimed to identify changes in EUS findings of autoimmune pancreatitis (AIP) in response to steroid therapy.

Methods: We enrolled 37 patients with AIP and performed EUS before and 2 weeks after steroid therapy to evaluate EUS findings in response to the therapy. Furthermore, we compared the EUS and histopathological findings on AIP in 2 patients who underwent pancreatectomy.

Results: The EUS findings revealed no significant changes in the prevalence of hyperechoic strands and hypoechoic swelling 2 weeks after steroid therapy. In contrast, the prevalence of lobularity significantly decreased from 48.6% to 21.6% after steroid therapy, with a more pronounced reduction in focal AIP (63.6% to 18.2%). Histopathological analysis revealed that lobularity was corresponded to storiform fibrosis between lobular structures infiltrated with immunoglobulin G4-positive plasma cells.

Conclusion: Lobularity in AIP was the most responsive EUS finding to the steroid therapy. Focal lobularity was corresponded to storiform fibrosis between lobular structures infiltrated by IgG4-positive plasma cells. Thus, our findings might help elucidate the pathogenesis of AIP that is responsive to steroid therapy.

Summary: Background: Serum thrombospondin-2 (TSP-2) plays a role in various biological processes, including collagen and fibrin formation. Preclinical studies have implicated TSP-2 in liver fibrosis and renal impairment. However, the clinical significance of serum TSP-2 levels in relation to liver and renal function in the general population remains unclear. This study aimed to investigate the association between serum TSP-2 levels and the severity of hepatic fibrosis or renal dysfunction.

Methods: A cross-sectional study was conducted in Uku Town, Nagasaki Prefecture, Japan, in 2019. A total of 225 participants were enrolled, and serum TSP-2 levels were directly measured. Univariate and multivariate analyses were performed to assess the relationship between TSP-2 levels and hepatic fibrosis severity or renal dysfunction.

Results: The mean ± standard deviation (SD) age of the participants was 69.0±7.9 years. Serum TSP-2 levels were significantly elevated with increasing FIB-4 index scores (p = 0.003) and progressively increased with decreasing estimated glomerular filtration rate (eGFR) levels (p = 0.027). Furthermore, the association between TSP-2 levels and the FIB-4 index remained statistically significant (p < 0.001) after adjustment for age, sex, and potential confounders.

Conclusions: These findings suggest a significant association between serum TSP-2 levels and both liver fibrosis and renal dysfunction, even in a healthy Japanese general population.

Summary: Purpose: Inferior mesenteric artery node (IMAN) metastasis is rare in left-sided colorectal cancer. Tumor depth is a risk factor for IMAN metastasis, but other risk factors are unclear. This study investigated the frequency of IMAN metastasis and examined clinicopathological risk factors associated with this metastasis in left-sided colorectal cancer. We also aimed to evaluate the clinical benefit of routine D3 lymphadenectomy in surgically treated advanced colorectal cancer.

Methods:We retrospectively studied patients with colorectal cancer who underwent D3 lymphadenectomy and R0 resection at Kurume University Hospital from 1996 to 2017 to identify the frequency and risk factors for IMAN metastasis to investigate the long-term prognosis. Clinicopathological factors associated with IMAN metastasis were analyzed.

Results: Among 949 consecutive patients, IMAN metastasis was observed in 8 (0.84%) patients. The 5-year overall survival rate was significantly lower in the IMAN metastasis-positive group (68.6%) than in the IMAN metastasis-negative group (83.7%) (p = 0.025).

Conclusion:IMAN metastasis is a poor prognostic factor for left-sided colorectal cancer, but this metastasis has a 5-year survival rate of 68.6%.

Summary: Introduction: Electrocardiographic (ECG) changes associated with biliary diseases, including cholecystitis and cholangitis, have been sporadically reported; however, detailed observational data remain scarce. This study aimed to investigate the prevalence and characteristics of ECG abnormalities in patients with cholecystitis and cholangitis, and to identify associated clinical factors.

Materials and Methods : We conducted a retrospective analysis of 402 patients hospitalized for biliary diseases between January 2018 and January 2025. After excluding patients without comparable ECGs or with confounding cardiovascular conditions, 79 cholecystitis and 111 cholangitis cases were included. ECG changes such as T-wave abnormalities, ST-segment deviations, and conduction blocks were evaluated. Clinical variables, including demographics, laboratory results, disease severity (Tokyo Guidelines), and comorbidities, were compared between patients with and without ECG changes.

Results: ECG abnormalities were observed in 43% of cholecystitis cases and 34% of cholangitis cases. In both groups, T-wave abnormalities—particularly negative T-waves—were the most common findings, followed by ST-segment changes and conduction blocks. In cholecystitis, ECG changes were significantly associated with lower serum potassium levels and higher disease severity. In cholangitis, a history of stroke and elevated alkaline phosphatase (ALP) levels were significantly associated with ECG changes. All ECG abnormalities normalized following appropriate treatment of the underlying biliary disease.

Conclusion:Electrocardiographic changes were observed in a significant proportion of patients with either cholecystitis or cholangitis. Awareness of the potential association between biliary disease and electrocardiographic abnormalities is essential to avoid misdiagnosis and to ensure appropriate management in acute care settings.

Summary: This study aimed to investigate anatomical features by comparing and verifying the shape of the talus and calcaneofibular ligament (CFL) depending on the number of anterior talofibular ligament (ATFL) bundles. We also aimed to reveal the relationship between the ATFL and talofibular and CFL. We examined 118 feet from 59 cadaveric specimens and measured the ATFL and CFL, as well as the length, width and thickness of the talus and foot, by using digital calipers. We counted the number of ATFL bundles, calcaneofibular ligament, talus and foot. The ATFL was divided into two groups: one group with one bundle and one group with two bundles. We further examined the relationship between the shapes of the ATFL, CFL, talus and foot. The results were tested for differences in sex and showed that women had significantly wider (p<0.05) and longer (p<0.05) talus in the two-bundle group than in the one bundle group. The CFL was also significantly longer in the two-bundle group (p<0.05). A moderately significant correlation was found between the shapes of the ATFL and the talofibular and CFL. This study provided new anatomical findings that the ATFL attached to the high talus has two bundles. In addition, the ankle joint evaluation and rehabilitation was basic research that considered sex differences.

Summary: Objectives: We aim to establish support for bereaved families during the anticipated recurrence of an infectious pandemic by clarifying the relationship between the experiences of bereaved families during the COVID-19 pandemic with their depression symptoms and post-traumatic growth (PTG). Methods: We surveyed bereaved family members who lost their loved ones during the COVID-19 pandemic. Participants were asked to answer questions regarding “experiences of bereaved families during the COVID-19 pandemic,” “depressive symptoms,” and “PTG.” Multivariate analysis was then performed to examine their correlations. Results: Individuals were anxious about contracting an infection and those who had lost a spouse or partner were more likely to experience depression. In addition, a lack of satisfactory interactions with the deceased prior to death can lead to depression. Those who had satisfying interactions with medical professionals and who received support from medical professionals and neighbors tended to have higher PTG scores. Conclusion: During pandemics, meaningful interactions with the deceased prior to death and adequate social support for bereaved individuals, especially those who have lost their spouses or partners, is important.

Summary: Purpose: To compare the clinical efficacy and treatment burden between a modified treat-and-extend (mTAE) regimen and a pro re nata (PRN) regimen of intravitreal aflibercept in patients with macular edema (ME) secondary to branch retinal vein occlusion (BRVO).

Methods: This retrospective study included 17 eyes in 17 treatment-naïve patients with BRVO-associated ME who received intravitreal aflibercept at Kurume University Hospital. Patients were assigned to either the mTAE group (n=9) or the PRN group (n=8). The primary outcomes were the changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT) over 12 months. The secondary outcomes included the numbers of injections and clinic visits.

Results: Mean BCVA improved by 9 ETDRS letters in the mTAE group and 6 letters in the PRN group at 12 months. Both groups achieved significant improvements in CMT at 12 months, with no significant differences between the two groups. The mean number of injections was 5.1±1.5 in the mTAE group and 3.8±1.6 in the PRN group (p=0.14). However, the mTAE group had significantly fewer clinic visits than the PRN group (8.0±1.6 vs. 10.9±3.0; p=0.04). No serious adverse events were observed in either group.

Conclusion: Both the mTAE and PRN regimens of intravitreal aflibercept effectively reduced ME in BRVO patients over 12 months. However, the mTAE approach significantly reduced the frequency of clinic visits without compromising the efficacy, suggesting that it may be less burdensome for patients and clinics for the management of BRVO-ME in real-world practice. These findings support the use of an individualized treat-and-extend strategy to maintain clinical benefits while alleviating the treatment burden in BRVO patients.

Summary: Purpose: We aimed to develop a generalizable machine learning model that leverages electronic medical record (EMR) data to predict candidemia using information available on or before the date of blood culture collection.

Methods: This study included adult patients admitted to Shin Koga Hospital (April 2014–March 2022) who underwent blood cultures at least 14 days after admission. We prepared two datasets: a “Complete case dataset” (13 variables, no missing values) and a “Imputed full-variable dataset” (36 variables, single imputation). We evaluated the discriminative performance of four machine learning models, including extreme gradient boosting, random forest, least absolute shrinkage and selection operator (LASSO) logistic regression, and logistic regression using stratified 5-fold cross-validation by comparing their area under the receiver operating characteristic curve (AUROC). The model with the highest mean AUROC was selected, assessed on the entire dataset, and internally validated using 1,000 bootstrap replicates.

Results: A total of 919 patients were included, of whom 47 (5.1%) had candidemia. The LASSO logistic regression demonstrated the best performance and was selected as the final model. The AUROC (95% CI) was 0.880 (0.836–0.924) for the Complete case dataset and 0.913 (0.878–0.948) for the Imputed full-variable dataset. The optimism-corrected AUROCs were 0.851 and 0.876, respectively.

Conclusion: We developed two versions of the LASSO logistic regression model using only information automatically extracted from EMR, considering real-world data availability. These models have the potential to serve as practical tools to support early diagnosis and therapeutic intervention for candidemia.

Summary: Purpose: Patients with interstitial lung disease (ILD) often experience postoperative acute exacerbation (AE). There is a lack of consensus regarding the risk factors for postoperative AE. This study aimed to identify factors associated with postoperative AE in patients with ILD.

Methods: Of 84,833 patients who underwent surgery under general anesthesia, we included 198 ILD patients. The patients were retrospectively divided into AE and non-AE groups. Exclusion criteria were those who were continuously on a ventilator preoperatively or postoperatively, and those with obvious infection. We investigated risk factors, adjusting for sex and pulmonary surgery.

Results: AE occurred within 30 days after surgery in 11 patients (5.6%) and six of these patients (55%) died. Preoperative C-reactive protein (CRP) levels were significantly higher in the AE group than in the non-AE group (OR, 1.06; 95% confidence interval [CI], 1.00–1.13; p = 0.048). Chest high-resolution computed tomography (CT) evaluation was performed according to the updated 2022 idiopathic pulmonary fibrosis guidelines. CT revealed that patients in the CT-defined usual interstitial pneumonia (UIP) group, comprising UIP and probable UIP patterns, were significantly more likely to experience AE than those in the non-CT-UIP group, which included indeterminate UIP and alternative diagnosis patterns (OR, 4.00; 95% CI, 1.19–15.04; p = 0.025).

Conclusion: In patients with ILD, the risk of postoperative AE across all surgeries, including non-pulmonary surgery, was associated with high preoperative CRP levels and the CT-UIP pattern.

Summary: This report describes a left inferior vena cava (LIVC) found during the dissection of an 85-year-old female cadaver, a rare anatomical variation with a prevalence of 0.05% to 0.69%. The LIVC ascended on the left of the abdominal aorta before crossing to the right to continue as the typical inferior vena cava. Notable variations were observed in the iliac venous system and renal vessels. Awareness of such anatomical variations is crucial for accurate diagnosis and to prevent complications during abdominal surgeries, emphasizing the importance of thorough preoperative planning and imaging.

Summary: Congenital diaphragmatic hernia (CDH) diagnosed in the first or early second trimester is exceedingly rare. We herein present a unique case of Emanuel syndrome identified through early sequential findings of increased nuchal translucency (NT) and CDH. A 34-year-old Japanese woman was referred at 14 weeks of gestation because of an elevated NT of 3.9 mm detected at 12 weeks, with no other markers of aneuploidy. At 15+1/7 weeks, an ultrasound revealed right-sided heart displacement, a tubular structure near the heart, and a cystic structure on the left, presumed to be the stomach and intestines, respectively—findings indicative of CDH. Fetal karyotyping via amniocentesis confirmed Emanuel syndrome with a karyotype of 47,XY,+der(22) t(11;22)(q23.3;q11.2). This case suggests that early detection of increased NT could lead to the early diagnosis of CHD, which, in our case, was part of Emanuel syndrome.

Summary: A 67-year-old woman was referred for cardiac tumor. Computed tomography scans revealed a large mass occupying the left atrium causing the left pulmonary vein obstruction and pulmonary congestion. Positron emission tomography / computed tomography (PET/CT) showed abnormal accumulation at the border between the left atrium and the left pulmonary vein orifices, and the invasion of the malignant cell to the left upper and lower pulmonary veins was highly suspected.

Operative finding was that the tumor was attached to the left atrial posterior wall adjacent to the left pulmonary vein orifices and extended to the left upper pulmonary vein about 1 cm beyond the left upper pulmonary vein orifice. The tumor was not extended to the left lower pulmonary vein. Considering the possibility that the tumor was a sarcoma, for which chemotherapy was less effective, radical resection including left upper lobectomy and reconstruction of the left atrium was considered, but a rapid intra-operative histological exam revealed a malignant lymphoma. Therefore, surgery was performed to reduce the tumor as much as possible. The postoperative course was good and the patient was treated with chemotherapy, surviving for 18 months without any signs of recurrence.

Summary: Focal fatty change (FFC) can exhibit various patterns. Therefore, multifocal cases may require differentiation from metastatic liver tumors because the diagnosis is challenging in case of a history of treatment for malignant tumors. Herein, we report the case of a 65-year-old man with FFC who underwent total pancreatectomy for advanced intraductal papillary mucinous carcinoma. In this case, regular replacement of the percutaneous transhepatic cholangial drain was performed for postoperative anastomotic stenosis. The FFC showed a multifocal pattern with arterial-phase hyperenhancement and washout patterns; therefore, differentiation from not only metastatic liver tumors but also from hypervascular liver tumors including hepatocellular carcinoma was required. This case report highlights that although FFC can have a variety of imaging patterns; it can present arterial-phase hyperenhancement and washout patterns.

Summary: Objective: Ascending pulpitis refers to inflammation of the dental pulp that progresses from the apical region toward the coronal portion of the tooth. The purpose of this study is to investigate novel insights into the pathophysiology of OMS arising from marginal periodontitis with ascending pulpitis.

Methods: Five adult patients diagnosed with OMS arising from marginal periodontitis were examined. Histological analysis of the causative teeth of OMS was conducted.

Results: No coronal lesions (e.g., dental carious lesions) were observed in the causative teeth of OMS. Histologically, the periodontal ligament of the involved teeth exhibited necrosis, confirming the presence of marginal periodontitis. Within the pulp cavity of the causative tooth, both odontoblasts and pulp cells had disappeared, and necrosis was observed in the root canal and portions of the pulp chamber, indicating ascending pulpitis and pulpal necrosis. Additionally, inflammatory granulation tissues were present at the apex, consistent with apical periodontitis.

These findings of the causative teeth of OMS suggest the following pathological sequence: marginal periodontitis initiated ascending pulpitis and pulpal necrosis of the tooth; these, in turn, led to the development of apical periodontitis, which subsequently caused OMS.

Conclusion: In cases with absence of coronal lesions (e.g., dental carious lesions), diagnosing ascending pulpitis and pulpal necrosis is challenging and is not always straightforward. A thorough understanding of the pathophysiological progression – from marginal periodontitis to ascending pulpitis, pulpal necrosis and apical periodontitis that ultimately leads to OMS – is essential. Clinicians must maintain a high level of suspicion for this condition in daily practice.

Summary: A 34-year-old woman with a monochorionic diamniotic twin pregnancy developed twin-to-twin transfusion syndrome and selective fetal growth restriction at 21 weeks, followed by the onset of twin anemia-polycythemia sequence at 23 weeks. Fetoscopic laser photocoagulation could not be performed. Therefore, the pregnancy was managed expectantly. By 24–26 weeks, amniotic fluid levels and cerebral Doppler parameters normalized, but the donor twin’s cardiac function deteriorated progressively. At 26 weeks, neurosonography showed diffuse periventricular hyperechogenicity, followed by ventriculomegaly at 28 weeks. Cesarean delivery was performed at 34 weeks because of preeclampsia. The donor twin was severely anemic, showed cerebral atrophy, and died on day 6. The recipient remained stable. This case illustrates the natural progression and dynamic interplay of three clinical conditions, resulting in hypoxic–ischemic brain injury in the donor twin. Our findings indicate the importance of cardiovascular monitoring to understand the complex pathophysiology in such pregnancies.