In recent years, there have been an increasing series of reports of diagnostic error because, unlike before, medical treatment has become segmented, and the diversity of diseases has increased with the aging of the population, so many doctors are now involved in diagnosing a single patient. It is difficult for other healthcare workers to determine whether the attending physician has confirmed the contents of the radiology report created by the radiologist, so the medical safety manager cannot grasp the actual situation, making it difficult to take countermeasures against diagnostic error.
Therefore, in this hospital, the medical safety manager decided to add a physician confirmation button to the electronic medical chart of the radiology report to indicate whether the attending physician has confirmed the findings of the radiology report and to reduce the number of unconfirmed reports. In August 2018, a physician confirmation button was added to the radiological image interpretation system, and the status of attending physicians confirming the radiology reports was continuously investigated and examined over a survey period of 1 year and 4 months.
At the time the button was added, there were 6102 image interpretation reports per month across the entire hospital. Of these, 2610 reports (42.7%) were confirmed. As a result of continuous instruction to the physicians to reduce the number of unconfirmed reports, the confirmation status improved to 98.6% of the total 95,616 reports as of December 2019, the end date of the survey. The rate of unconfirmed reports plummeted to 1.4%.
Radiology interpretation reports prepared by radiologists often point out disease to the attending physician in areas other than the area of interest. Thus, this method appeared to be useful in reducing diagnostic error due to unconfirmed radiology reports, which has become a problem in recent years.

Data on long-term renal outcomes of childhood-onset (<16 years old) diffuse global proliferative lupus nephritis with active lesions identified by the International Society of Nephrology/Renal Pathology Society as “IV-G (A)-cLN” are scarce. The present study retrospectively analyzed demographic, clinical, laboratory, and disease-related psychosocial data of 34 children diagnosed as having IV-G (A)-cLN between 1991 and 2005 who completed a direct and consecutive 10-year follow-up. At 10 years post-diagnosis, the mean estimated glomerular filtration rate (eGFR) was 51.1 ml/min/1.73 m². The subgroup with eGFR<60 ml/min/1.73 m²-at 10 years post-diagnosis showed a slow but significant decline in eGFR during the first 5 years, followed by a steep gradient during the subsequent 5 years, compared with that of the subgroup with eGFR≥60 ml/min/1.73 m²-at the same time point. As significant influencing factors for the initial 5-year slow decline in eGFR, a treatment-refractory active disease status and a proteinuric flare (urine protein [g]/creatinine [g] ratio >1) were observed because of the short duration of mycophenolate mofetil use (2 years). The physical/psychosocial impact of the disease on adolescent and young adults, and subsequent nephritic flares (disease relapse with acute kidney injury), were significantly related to the ensuing 5-year steep decline in eGFR. Multivariate analysis revealed renal tubular epithelial cell casts >10 per high -power field on urinalysis as early- and later-phase prognostic indicators of progressive chronic kidney disease in IV-G (A)-cLN. This report showed a two-stage (i.e., slow-then-steep) pattern of loss of renal function in IV-G (A)-cLN, influenced by multiple biologic/behavioral factors over a 10-year period of continuous observation. Renal tubular epithelial cell casts in a simple urinalysis may be a useful marker to assess disease activity over the entire course. To improve long-term renal outcomes, more research is warranted regarding intensive intervention, monitoring, and longer observation of these prognostic indicators.

Purpose: We investigated the values of deviant hepatic enzyme levels in asymptomatic children with Down syndrome and compared them with the reference values.
Methods: We extracted follow-up blood sampling data of children with Down syndrome who visited the St. Marianna University School of Medicine from 2013 to 2018. We compared the data with the Japanese standard laboratory values for children.
Results: The values of deviant hepatic enzymes in the children with Down syndrome were higher than the standard values and were frequently higher than the median values. Aspartate aminotransferase (AST) levels were twice as likely, and alanine aminotransferase (ALT) levels were 18 times as likely, to exceed the median values. Although many children with Down syndrome are obese, among the children whose values of deviant hepatic enzymes exceeded the standard values in our study, 85% of those under 18 years of age were not obese.
Conclusions: In the present study, children with Down syndrome tended to have increased levels of AST and ALT.

Objectives: Patients with lysosomal storage diseases (LSDs) are rarely diagnosed until the presence of their serious condition. Promising therapeutic options are available for LSDs, but treatments should begin before symptoms appear. A newborn screening (NBS) is expected to be developed for early diagnosis. To understand parents’ attitude toward an NBS for LSDs, we conducted a cross-sectional study using a questionnaire.
Method: We targeted parents of children who visited St. Marianna University School of Medicine Hospital and Kawasaki Municipal Tama Hospital from January 2019 to November 2019 for their infant’s 1-month checkup. We investigated their awareness of NBS, the acceptable cost for a novel NBS, necessary information, preferred time and method of providing that information. We also received responses from medical professionals and students in the St. Marianna University School of Medicine using the same questionnaire.
Result and Discussion: We received the responses from 443 parents and 127 medical staffs. The responses we received showed that only one half of the individuals were aware of the NBS program. Among the responders, only 6.3% of the parents and 21.9% of the healthcare professionals knew the details of NBSs for LSDs, but 74.3% of the parents and 93.6% of the medical staff indicated that they would like their children to have NBSs and that they would pay the additional costs for the new NBS for LSDs. Both groups also indicated that the most preferable way to receive information on NBS would be through individual explanation from medical staff including medical doctors during pregnancy.
Conclusion: Our study showed that newborn screening for LSDs is not well known as previous studies also showed. However, once parents knew about the test, most of them were willing to have their children undergo an NBS. In addition, medical professionals including medical students who have more knowledge about LSDs preferred to have the NBS. It is important to be aware of rare but treatable diseases and inform the expectant parents about NBS at the appropriate time.

Background
In patients with extracranial carotid atherosclerotic disease (ECAD), comorbid intracranial atherosclerotic disease (ICAD) causes high stroke recurrence and mortality rates. We hypothesized that the properties of carotid atherosclerosis are related to the risk of ICAD; however, this hypothesis has not been confirmed. Therefore, we aim to clarify the factors associated with the risk of ICAD in patients with carotid artery stenosis by measuring the properties of carotid atherosclerosis and arteriosclerosis-related biomarkers.
Materials & Methods
A total of 50 patients with atherosclerotic carotid artery stenosis were included in the study. ICAD was defined as stenosis of 50% or greater, affecting the large intracranial arteries on magnetic resonance angiography. The associations between carotid atherosclerosis properties measured via magnetic resonance imaging (MRI) black blood method, ultrasonography, and arteriosclerosis-related biomarkers (oxidized LDL, LOX-1, MPO, PTX3, MMP-9, hsCRP) were examined using univariate analysis between patients with and without ICAD.
Results
ICAD was detected in 15 of 50 patients (30%), all of whom had middle cerebral artery stenosis. Univariate analysis revealed associations between ICAD and the MMP9 value (p=0.03) and the high-sensitivity CRP value (p=0.02).
Conclusion
In patients with atherosclerotic carotid artery stenosis, the serum MMP-9 level was associated with the risk of ICAD while other markers of atheromatous plaques, detected by MRI and carotid ultrasonography, were not. These results may suggest a role for MMP-9 in the progression of ICAD.

A 75-year-old woman presented with chronic rheumatoid arthritis. She was scheduled for detailed examination because her routine blood test results showed elevated hepatic and biliary enzymes. An upper gastrointestinal tract endoscopy revealed an exposed tumor in the duodenal papilla. We took a biopsy, and the tumor was diagnosed as poorly differentiated adenocarcinoma. Based on these findings, the patient was diagnosed with cancer of the duodenal papilla and we performed pylorus-preserving pancreaticoduodenectomy. The histopathological findings of the surgical specimen revealed moderately differentiated adenocarcinoma with a hollow structure. In addition, we found that atypical cells with strong nuclear atypia had formed a solid alveolar structure with microvasculature within the tumor. Since both synaptophysin staining and chromogranin staining were positive by immunostaining, the component of solid alveolar structure was diagnosed as neuroendocrine carcinoma. However, because it comprised ≥30% components of both adenocarcinoma and neuroendocrine tumor, the final diagnosis was mixed neuroendocrine non-neuroendocrine neoplasm (MiNEN). The postoperative course was uneventful and she was discharged on Postoperative Day 13. Hepatic metastasis recurrence appeared 3 months after the operation, but the patient refused the recurrence treatment and died 2 years after the operation. Although standard treatment has not been established for MiNEN, it is important to perform surgical resection with group 2 lymph node dissection in accordance with the standard treatment of pancreatic and gastrointestinal NEC and to perform platinum chemotherapy after surgery or recurrence.

A 71-year-old man was referred to our hospital for a rectal tumor found by a colonoscopy. Further examinations recealed rectal adenocarcinoma with liver metastasis (cT4aN2aM1a, cStage IVa). After neoadjuvant chemotherapy, he underwent low anterior resection of the rectum with ileostomy, followed by postoperative adjuvant chemotherapy. After confirming reduction of the hepatic tumor without the appearance of new metastatic lesions, resection of the hepatic tumor and closure of the ileostomy were performed. Histologically, the tumor lacked evidence of metastatic rectal cancer and consisted of numerous small vessels in fibrous stroma with hyalinization, indicative of a sclerosing hemangioma. This case of hepatic sclerosing hemangioma was radiologically difficult to differentiate from liver metastasis of rectal cancer.

We report the case of a 22-year-old man who presented with a mass in his right cheek and frequent swelling of his right upper gum. Clinical and radiological examinations revealed an organized hematoma (OH) in the right maxillary sinus. Thus, endoscopic resection of the lesion was performed after preoperative embolization in the right mandibular artery.
OH is a rare hemorrhagic lesion mostly occurring in the sinonasal cavity. Nasal bleeding and nasal obstruction are the primary clinical features of OH. Although this lesion is relatively common in otolaryngology, it is rarely seen in the plastic surgery field; therefore, a careful diagnosis should be made. To our knowledge, this is the first case study in the literature to report an OH in the maxillary sinus, which was recognized as a subcutaneous tumor with bone destruction.

A 70-year-old Japanese man was referred to our hospital. He had sigmoid colon carcinoma (cT3 N3 M0, cStage IIIb) with liver cirrhosis (Child classification, grade B), hepatocellular carcinoma (cT3 N0 M0, cStage III), and esophageal varices (Ls, F2, Cb, RC0, and Te). A self-expandable metallic stent (SEMS) had already been inserted. Considering the potential complications, radical surgery for the colon carcinoma was thought to be intolerable. The esophageal varices were treated with endoscopic injection sclerotherapy, and the hepatocellular carcinoma was treated with transcatheter arterial chemoembolization. During the clinical course, malignant obstruction due to ingrowth of the colon carcinoma was repeatedly experienced. Additional stent-in-stent SEMS insertion was successfully performed each time for a total of three times. The serum albumin level rose after each time SEMS was reinsertion. The patient died of progression of the hepatocellular carcinoma 369 days after the first SEMS insertion.

The patient was a 79-year-old woman who visited a local physician because of persistent epigastric pain and vomiting that led to difficulty in oral ingestion and was referred to our hospital for further examination. Computed tomography scans of the chest and abdomen showed that the stomach and transverse colon had migrated into the mediastinum and an upside-down stomach with gastric volvulus in a mesenteroaxial fashion. Radiographic contrast of the upper gastrointestinal tract showed that the stomach was inverted and that the entire stomach had prolapsed into the mediastinum. Thus, the patient was diagnosed with type IV esophageal hiatal hernia with upside-down stomach, and laparoscopic repair was performed. The surgery was performed with the patient in an open-leg supine position with five ports. Surgical findings revealed an esophageal hiatal hernia that was approximately 80×60 mm, with invagination of the entire stomach and transverse colon within the mediastinum. After reduction of the prolapsed organ into the abdominal cavity, the diaphragmatic limb of the esophageal hiatus was closed with nonabsorbable sutures, and the esophageal hiatus was reinforced using mesh. Additionally, Toupet fundoplication was performed. The postoperative course was uneventful. Oral intake was initiated at postoperative day (POD) 4, after which oral intake stabilized, and the patient was transferred to a rehabilitation hospital on POD 20. Upside-down stomach is associated with gastric volvulus and situations where the stomach is highly prolapsed into the mediastinum are relatively rare. Here, we report a patient with type IV esophageal hiatal hernia with upside-down stomach that was repaired laparoscopically.

In recent years, perioperative management has changed to enhance both the prevention of postoperative complications and early recovery of physical strength. At St. Marianna University School of Medicine, Yokohama City Seibu Hospital, we thought it necessary to review postoperative analgesia methods, bed rest time, fasting time, and other factors. We conducted an anonymous patient-reported questionnaire survey of 300 adult patients who underwent routine surgery from March 31 to April 30, 2016. We examined the cases of 176 patients undergoing general anesthesia among the 193 survey responders. As a result, 52% of patients felt that their pain was unpleasant, 45% felt uncomfortable with a dry mouth, 42% felt uncomfortable with the length of bed rest, 21% felt hungry, and 18% felt nauseous. Twenty-five (25%) of the 91 patients with a urethral catheter felt it to be uncomfortable. These results indicated that postoperative pain management, time on bed rest, oxygen administration time, and fasting time could be reviewed and that the postoperative recovery process could be improved. Now, we have revised our policy to allow the anesthesia department to provide some of the postoperative instructions to patients that were previously provided by the department in charge. Also, we are revising the clinical path in cooperation with the Clinical Path Committee.