We evaluated the predictive performance of severity predictive markers for coronavirus disease-2019（COVID-19）during the Omicron strain epidemic. Patients (n=853) who were admitted to our hospital from December 2021 to March 2023 and had laboratory test data at the hospitalization were included for this analysis. Patients were divided into two groups; severe group (n=58) used HFNC (High-Flow Nasal Cannula) or ventilator, or death, and non-severe group (n=795) recovered without HFNC or ventilator. Logistic regression analysis was performed on items for which a significant difference was observed in univariate analysis. Increased C-reactive protein (CRP) (odds ratio 1.11, 95% CI: 1.07-1.16), decreased albumin (odds ratio 0.35, 95% CI: 0.20-0.62), increased creatinine (odds ratio 1.74, 95% CI: 1.27-2.37) were identified as severity predictive markers with significant difference (P＜0.05). The results of the present study suggest that CRP, albumin, and creatinine would be predictive factors of the severity of COVID-19 during the Omicron strain epidemic.

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Since 1994, we have used the rhomboid flap technique (hereinafter referred to as this method), a classic flap technique for repairing small skin defects, to remove breast tumors, and have achieved results in repairing wide skin defects of more than 100 square centimeters. This method has been actively applied to fill defects in mastectomies and partial mastectomies to avoid disfigurement and complete removal of breast cancer lesions, and we believe that it can also be applied as an oncoplastic surgical technique. This time, we will report on the use of this method to fill in a wide range of skin defects during surgery for a case of advanced breast cancer with marked breast deformity.

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Laparoscopic surgery was the standard treatment for esophageal achalasia, but in recent years POEM, a new endoscopic treatment, has become popular as a minimally invasive treatment. However, it has been reported that the facilities where the POEM can be performed are limited institution and that reflux esophagitis occurs with a certain frequency after POEM. Here we report a case in which lower esophageal stricture occurred after undergoing two times of POEM, and surgical treatment was indicated. The patient is a 78-year-old woman. After administering two times of POEM for esophageal achalasia, she complained vomit after diet. She visited our hospital. Barium swallowing revealed dilatation of the thoracic esophagus with stricture of the lower esophagus. Because of repeated vomiting, proximal gastrectomy with lower esophagectomy was performed laparoscopically. Postoperatively, anastomotic stenosis was observed, but the patient improved conservatively and was discharged from the hospital. Cases of stenosis after POEM have not been reported and are extremely rare.

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A 49-year-old woman had persistent fever of 39℃ or higher for more than 7 days after trekking to Tenkawa Village, Nara Prefecture, and visited our department on the 9th day of onset to investigate the cause of the fever and liver dysfunction. Blood tests showed no increase in white blood cell count (5900/μL), disappearance of eosinophils, appearance of atypical lymphocytes of 1.5%, liver dysfunction (AST166 U/L, ALT191 U/L, r-GTP135 U/L, LDH685 U/L, ferritin 1424.7ng/mL) and elevated inflammatory response (CRP 15.34mg/dl, blood sedimentation rate 65mm/h), but no thrombocytopenia was observed. She also had no erythema on her extremities and trunk at the time of her presentation, but a 5 mm central bloody eschar on the posterior surface of her right lower leg was suspected of being a tick bite. She started outpatient treatment with instructions to take 1 tablet of minocycline (100 mg) twice a day and an oral rehydration solution of 1 L/day to treat rickettsial infection. The patient's fever subsided 9 days after the start of treatment, and the liver dysfunction and elevated inflammatory response improved over time, so oral treatment was discontinued 19 days later. Paired serum tests during the acute phase (9th day of onset) and convalescent phase (20th day of onset) confirmed a 320-fold increase in Japanese spotted fever Rickettsia IgM antibody titer, and based on the clinical course, a final diagnosis of Japanese spotted fever was made.

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今回、私がよくする手術、そのコツ その3：褥瘡手術-今こそ院内連携でしょ-と銘打ち、褥瘡に対する形成外科的アプローチを述べる。代表症例として、88歳女性、要介護V、胃瘻増設中で未治療の両肩関節脱臼骨折を認め、持ち込みの仙骨部褥瘡ステージIVに対して、褥瘡チーム、栄養科、リハビリ科が介入し、全身状態と創部状態を数か月で改善させ、穿通枝皮弁による被覆ができた。チーム医療が奏功した貴重な症例を経験した。

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The proportion of elderly people and the prevalence of diabetes mellitus (DM) in our country are increasing with changes in lifestyle and social environment. As for the treatment of DM, appropriate treatment is necessary because it causes various complications such as retinopathy, nephropathy, and neuropathy. It has also been reported that persons with DM have a higher prevalence of constipation and diarrhea than patients without DM, which is associated with hard stools, residual stools, and sudden bowel movements, resulting in a lower mental and physical quality of life. In addition, elderly persons should be aware of the development of fecal embolization, in which a fecal mass accumulates in the rectum due to pathological abnormalities specific to the elderly, such as decreased colon motility and blunted rectal sensory threshold. Magnesium oxide should be used first in the treatment of non-elderly persons, but hypermagnesemia should be noted in the elderly. Since the medical practice is changing dramatically with the recent introduction of many new drugs to treat constipation, we discussed the treatment of constipation in elderly persons with DM.

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Although maintenance of AVF (Arteriovenous Fistula) is important in hemodialysis, frequent PTA (percutaneous transluminal angioplasty) may be required due to progressive vessel stenosis, which is problematic. The latest KQOQI guidelines set a target of up to three PTAs per year for both AVF and AVG. IN.PACT AV DCB, the first DCB (drug-coated balloon) in Japan, is said to inhibit restenosis by inhibiting the growth of neointima with paclitaxel applied to the balloon surface. Intimal hyperplasia type, shrinking type, mixed type, and valve type are known as AVF stenosis forms. IN.PACT AV Access study showed the superiority of DCB in both De Novo and Restenotic groups. However, the difference in the effect depending on the stenosis form has not been examined. We thought that DCB might have little effect on shrinking type with less intimal hyperplasia based on its mechanism of action, and examined the treatment outcomes by stenosis form in cases of initial IN.PACT use at our hospital.

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Diabetes treatment has progressed greatly in recent years, with changes observed in wide areas, including large-scale clinical trials, guidelines, hypoglycemic agents, blood glucose monitoring, insulin pumps, and advocacy campaigns. Regarding hypoglycemic agents, two new oral drugs and three new injectable drugs have been launched on the market in the past three years. Automation of insulin pumps is also progressing. Advocacy campaign was proposed in 2019, and now we are now in an era where the Japanese term 'tounyou-byou' is about to change. It is essential for medical professionals to keep learning new information to provide better medical treatment tailored to each patient. We have summarized the recent changes in diabetes treatment.

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Familial Mediterranean fever is an autoinflammatory disease characterized by periodic fever and attacks of serositis. It is thought to be caused by an abnormality in MEFV gene. Fever of 38°C or higher and serositis (particularly peritonitis, pleuritis, and arthralgia) occur periodically, lasting for 12 to 72 hours and resolving spontaneously. A complication is reactive AA amyloidosis, which occurs when repeated attacks increase the production of amyloid A and deposit it in tissues. The first choice of treatment is colchicine, and the important point is to prevent attacks and avoid amyloidosis. Abdominal pain in FMF is mostly caused by peritonitis, and it has been thought that gastrointestinal mucosal lesions are rare. However, in recent years, there has been an increase in the number of cases reported in FMF patients with recurrent fever, abdominal pain, diarrhea and bloody stool, and gastrointestinal lesions resembling inflammatory bowel disease. Here we report a case of MEFV gene-related colitis with difficulty in differential diagnosis.

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Here, we reported that three cases of idiopathic omental hemorrhage treated conservatively. Case 1 was a 24-year-old man, Case 2 was a 47-year-old man, and Case 3 was a 72-year-old man. All patients came to our hospital because of sudden onset abdominal pain and fullness without any past medical history or trauma. In these cases, CT scan showed hematoma around stomach, but no obvious extravasation from the surrounding vessels. From their findings, we diagnosed idiopathic omental hemorrhage. The patient's vital sign was stable, so we indicated conservative treatment. Symptoms and anemia of the all patient improved, with no hemorrhage recurrence. Although surgical treatment has been choice for idiopathic omental hemorrhage, conservative treatment is considered one of the effective treatments when the patient's vital sign is stable.

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The V-RA series developed by ASAHI KASEI MEDICAL, are vitamin E immobilized hemodiafilters that are expected to reduce oxidative stress, and have superior biocompatibility compared to conventional polysulfone hemodiafilters (ABH). Reduction of inflammation, improvement of anemia, and increase in serum albumin levels are also expected for the V-RA series. Therefore, we evaluated and compared the biocompatibility and the solute removal efficiency of each V-RA and ABH series. As a result, V-RA showed a tendency to be slightly lower in solute removal efficiency than ABH. Decreases in white blood cell and platelet counts were observed in both V-RA and ABH series, which were milder in V-RA than ABH. As for the platelet factor-4, increases were observed in both V-RA and ABH series, which were also milder in V-RA than ABH. These results suggest that platelet activation was suppressed and that V-RA series had superior biocompatibility to ABH series.

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Based on the results of the October 2019 in-hospital triage assessment survey, we held a study session to increase the appropriateness rate, and conducted a re-survey of emergency outpatient patients in October 2022. As a result, the in-hospital triage appropriateness rate increased and the overtriage rate decreased.

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