Purpose. The aim was to investigate the utility of the eye-tracking pupillary reflex when testing for autonomic dysfunction in Parkinson’s disease (PD) patients by correlating the results with clinical status.
Methods. The eye-tracking video pupillometric evaluation of the pupillary reflex to light and the isometric hand grip task were measured in 45 PD patients (Hoehn & Yahr stage, 2-4; mean age, 72.7 ± 9.9 years; disease duration 7.2 ± 5.0 years; male, 53.3%). We performed consecutive measurements of pupil size, which were expressed as the number of pixels, and measured the light miosis response (LMiR) and light mydriasis response (LMyR) to changes in luminance (80 Lux and 400 Lux). We also calculated the mydriasis response to the isometric hand grip task (HMyR) as ratios to the pupil size before the stimulus.
Results. LMiR and LMyR were significantly smaller in PD patients than in controls (p = 0.002 and p = 0.006, respectively). Pupil size before and after the hand grip task and HMyR were similar to normal control values. LMiR in PD patients significantly correlated with Movement Disorder Society-Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) part 3 (p = 0.011) and part 4 (p = 0.003). LMyR correlated with MDS-UPDRS part 4 (p = 0.016). HMyR correlated with disease duration (p = 0.007) and levodopa equivalent daily dose (p = 0.025). Multiple linear regression analyses demonstrated that MDS-UPDRS part3 (p = 0.005) was significantly associated with LMiR. Disease duration (p = 0.037) was significantly associated with LMyR. But there was no clinical factor associated with HMyR.
Conclusion. An abnormal pupillary reflex, such as a low response to light stimulation and a high response to the hand grip task, may be observed in the advanced stage of PD.

Spinal cord injury (SCI) causes motor dysfunction. Induced pluripotent cells (iPSCs) are becoming a new source for cells that can be used in transplantation therapy without concern for ethical issues or immune rejection, but an optimally effective clinical strategy for transplantation remains to be developed. Human iPSCs (hiPSCs) satisfy the requirement for grafted cells, and Nerbridge, a conduit made of polyglycolic acid (PGA) and collagen, has been used as a scaffold for grafted cells and employed clinically for regeneration of peripheral nerves. This scaffold may be applicable not only for peripheral nerve injury but also for central nervous system injury. We conducted an experimental study in which we combined hiPSCs with Nerbridge and transplanted the cells into a murine SCI model, which we created by complete transection at Th11. Cells were transplanted into the injury site. Transplantation of neural stem/progenitor cells (NSPCs) with the nerve conduit improved motor function more effectively than did transplantation of a single cell suspension of NSPCs or implantation of a nerve conduit without NSPCs. Histologic analyses revealed a high percentage of transplanted cells expressing human nuclear antigen and a high percentage of neurofilament M-positive axons at the site of injury. Our results suggest that the combined application of NSPCs and a nerve conduit has potential as treatment for SCI.

Objective To determine the predictors of the therapeutic effects of tocilizumab (TCZ) switched from other biologics with different mechanisms of action in rheumatoid arthritis (RA).
Methods Patients who switched from tumor necrosis factor inhibitors (TNFis) or abatacept (ABT) to TCZ were analyzed. They were categorized into two groups based on clinical disease activity at week 24 (response group: 28-joint disease activity score with erythrocyte sedimentation rate (DAS28-ESR) (3) ≤ 3.2, and non-response group: DAS28-ESR (3) > 3.2). We compared DAS28-ESR (3) at the initiation of TCZ therapy (ΔDAS) in patients switching from TNFis and ABT. We examined whether the therapeutic effect of TCZ switched from TNFis and ABT could be predicted using clinical parameters.
Results Sixty-seven patients were analyzed (TNFis, 53; ABT, 14); of these, 36 (67.9%) patients who received TNFis and 6 (42.9%) who were treated with ABT were considered responders. In patients who switched from TNFis, ΔDAS in the non-response group was significantly lower than that in the response group until week 8, and the improvement in the non-response group reached a plateau at week 12. Conversely, in patients treated with ABT, ΔDAS was significantly different between the response and non-response groups in the early phase, i.e., at week 4. In univariate regression analysis, ΔDAS at week 4 was correlated with DAS28-ESR (3) at week 24 (p < 0.05) in patients switching from ABT. Receiver operating characteristic analyses suggested that 0.74 was the optimal ΔDAS cutoff at week 4 to predict response vs. non-response at week 24 (sensitivity: 100%, specificity: 87.5%, p < 0.001).
Conclusion The efficacy of TCZ may vary depending on which biologics were used previously. The effectiveness of TCZ switched from ABT could be predicted by the therapeutic response at week 4.

Background: Endotracheal intubation is a core skill for airway management. With regard to the expertise of endotracheal intubation among physicians using a rigid laryngoscope, the body movement, the head movement, and movement of the gaze during the intubation procedure vary for each physician. This study aimed to test the hypothesis that the duration of endotracheal intubation, head movement, and movement of gaze intra-procedurally differ between experts and novices and assessed these factors using both a motion capture system and eye-tracking system in a medical simulation setting.
Methods: After obtaining institutional approval, individuals who were either novices or experts at endotracheal intubation using Macintosh laryngoscopes were recruited. Body motion and gaze distribution during endotracheal intubation of a mannequin were recorded and analyzed using a motion capture system and eye-tracking system. The values obtained were compared between the novices and experts.
Results: The endotracheal intubation time was significantly shorter in experts (21.6 ± 7.6 sec vs 30.4 ± 8.3 sec, p=0.002), and the range of vertical head movement was smaller in experts (13.1 ± 7.7 cm vs 39.2 ± 8.1 cm, p<0.001), with significantly different trajectory, than those in novices. The ratio of downward gazing was significantly higher in experts (99.6 [96.7–100]% vs 32.4[18.8–43.4]%, p<0.001), and that of proximal gazing was significantly higher in novices (78.1 [67.9–85.6]% vs 37.2 [6.4–82.1]%, p=0.011).
Conclusion: Body movement and gaze dynamics during endotracheal intubation with rigid laryngoscope differed between novices and experts. This system is a potential and feasible tool for evaluating the practice of endotracheal intubation.

Objective: Recurrent laryngeal nerve (RLN) paralysis was previously believed to be a major cause of dysphagia after esophageal cancer surgery. However, reports from recent years have indicated that dysphagia may be caused by decreased laryngeal elevation due to cervical lymph-node dissection (LND). For this reason, we studied whether a relation exists between postoperative decrease in geniohyoid muscle mass and postoperative dysphagia in patients treated for thoracic esophageal cancer.
Methods and Results: Our study was retrospective and included 54 patients who underwent surgery for esophageal cancer at our hospital between April 2014 and August 2018. Computed tomography (CT) had been performed on postoperative days (POD) 5–8 and laryngeal video fluoroscopy on POD 7. The patients were divided between those with and without dysphagia and those with and without preoperative sarcopenia, and clinical variables were compared between the patient groups. The dysphagia group (n=12) had significantly lower postoperative prealbumin (PA) values (18±7 vs. 22±6; P<0.05) than the non-dysphagia group (n=42). Three-region cervical LND was performed in a greater percentage of patients in the dysphagia group than in the non-dysphagia group (9/3 (75.0%) vs 15/27 (35.7%); P<0.05). In addition, decreases in the psoas major and geniohyoid muscle cross-sectional areas were significantly less in the dysphagia group 93.0±5.1% vs. 98.4±8.3%; P<0.05 and 77.5±11.3% vs. 88.2±16.5%; P<0.05, respectively). The cross-sectional area of the geniohyoid muscle was significantly smaller in patients with preoperative sarcopenia than in those without sarcopenia 82.8±11.1% vs. 90.6±21.1%; P<0.05).
Conclusion: Our findings suggest that a postoperative decrease in geniohyoid muscle mass causes the dysphagia seen in patients after esophageal cancer surgery. In addition, dysphagia may occur more readily in patients with pre-existing sarcopenia.

Objectives Laparoscopic surgery is widely used for treatment of colorectal cancer. However, due to the restricted operating space in patients with rectal cancer, the degree of surgical difficulty is greater than that in patients with colon cancer. For assistance in planning the surgery, we have calculated the pelvic volume, rectal volume, and tumor volume to derive occupancy of the rectum and tumor in the pelvic cavity. In the study described herein, we calculated the rectal tumor area and pelvic area by measuring the maximum diameter of the rectal tumor and the diameter of the pelvis on selected computed tomography (CT) slices and the analyzed these areas in relation to surgical outcomes.
Methods Sixty-two patients diagnosed with upper rectal cancer at St. Marianna University Hospital between October 2012 and December 2018 were included in the study. All were treated by laparoscopic surgery, having undergone computed tomography colonography (CTC) preoperatively. We calculated the rectal volume occupancy and rectal area occupancy and performed statistical analyses to determine whether a relation exists between these measurements and the surgical difficulty encountered or incidence of anastomotic leakage.
Results Significant positive correlation (r = 0.603, p < 0.01) was found between area occupancy and volume occupancy. Surgical difficulty, as evidenced by a relatively high blood loss volume, was significantly increased among patients with an area occupancy ≥ 52.54% (p = 0.0146). The incidence of anastomotic leakage was significantly high among patients with high area occupancy (p = 0.011) and particularly high in those with area occupancy ≥ 52.54%.
Conclusion The rectal area occupancy determined by means of CTC is a useful predictor of the frequency of complications and level of surgical difficulty in patients with upper rectal cancer treated laparoscopically.

Background: Partial pressure of carbon dioxide (PCO₂) measured by capnometer is mainly used to evaluate the respiratory condition of the lungs under ventilator control. Recently, the use of bronchoscopy has been reported in the evaluation of lung function after lobectomy in patients with lung cancer and those with chronic obstructive pulmonary disease (COPD), who underwent bronchoscopic lung volume reduction (BLVR).
Objectives: To determine the usefulness of bronchoscopic capnometry to assess treatment sites for BLVR.
Method: Twenty patients with COPD suspected of having lung cancer who underwent transbronchial biopsy were included. PCO₂ was measured at the healthy side of the segmental bronchus under room air with a capnometer. Distribution of the percentage of low attenuation area (%LAA) as measured by chest computed tomography (CT), was calculated and compared to end-tidal CO₂ (EtCO₂) distribution obtained by the capnometer.
Results: All 20 patients displayed homogeneous patterns on CT, but the distribution of EtCO₂ as measured by capnometer was uneven in 3 patients. There was no significant correlation between %LAA and EtCO₂ in the 20 patients, but in 9 patients with higher %LAA values, %LAA correlation significantly with EtCO₂ (r = −0.437, p = 0.023).
Conclusions: Capnography was useful in physiologically evaluating local ventilation and perfusion status of the lung. We recommend capnography as an adjunct to CT to assess functional heterogeneity in patients potentially undergoing BLVR.

Japanese emergency departments have traditionally been separated into tertiary and secondary centers. Tertiary emergency centers focus on the care of trauma and critically ill patients, while secondary emergency centers operate with limited resources and only accept patients of a limited acuity from emergency medical services (EMS). In contrast, North American-style Emergency Departments (NAED) have been developed, with the aim of accepting both critical and non-critical patients. We conducted a retrospective, observational study using municipal EMS records from 2012 in a Japanese city. Our aim was to identify patient characteristics associated with long EMS transportation times to NAED in an urban city where both traditional and NAED centers are available. The primary endpoint was long transportation time, defined as >35 minutes. Other items included the distance of transportation from the scene (km), age, sex, reason for transportation (medical or surgical), relevant specialty determined by EMS, condition severity, number of EMS negotiations until acceptance, and the reason for diversion by other hospitals. Multivariate logistic regression was used to find characteristics associated with long transportation time. A total of 2934 patients were included in the analysis. Median transportation time was 29 minutes (IQR 21–38). Characteristics that were associated with long transportation time included age (years) (OR, 1.02; 95%CI, 1.02–1.03; P<0.01), patients with orthopedic (OR, 1.69; 95%CI, 1.08–2.66; P=0.02) or neurosurgical (OR, 1.72; 95%CI, 1.21–2.47; P<0.01) conditions, and the number of EMS negotiations until acceptance (OR, 4.08; 95%CI, 3.12–5.33; P<0.01). Long transportation times were negatively associated with patients with medical (OR, 0.66; 95%CI, 0.46–0.96; P=0.03) and ear nose and throat (ENT) (OR, 0.13; 95%CI, 0.04–0.44; P<0.01) conditions. This is likely because the NAEDs fill an unmet need for patients that require certain types of care, such as surgical or neurosurgical treatment, or because they accept patients that have been refused by other centers.

We encountered a case of pancreatic acinar cell carcinoma (ACC), which is a somewhat rare clinical entity. The patient was a 78-year-old woman who had been examined elsewhere for persistent upper abdominal pain that had begun a few months earlier. The examination revealed a neoplastic lesion in the head and tail of the pancreas. Contrast-enhanced abdominal computed tomography revealed a tumor measuring 42 x 59 mm in the tail of the pancreas with distinct margins and internal heterogeneity. Furthermore, solid portions suggestive of invasion of the main pancreatic duct were seen. Endoscopic retrograde pancreatography was performed, and cytologic examination of the pancreatic fluid led to a diagnosis of class V carcinoma. The tumor was located mainly in the pancreatic tail, but the ductal invasion extended into the pancreatic head. Thus, we performed radical total pancreatectomy. Histopathologic examination revealed proliferation of tumor cells with eosinophilic cell bodies as the main intraductal component, whereas the primary tumor comprised adenoid, cribriform, and solid structures. Upon immunohistochemical staining, the cells tested positive for Bcl-1 and negative for synaptophysin and chromogranin A, so pancreatic ACC was diagnosed (pT2N0M0-fStageIB). Pancreatic acinar cell carcinoma accounts for 0.4% of all pancreatic cancers in Japan, and invasion of the main pancreatic duct is rare.

This case report presents two hypertensive patients with severe sleep apnea (SA) who were effectively treated with optimized SA therapy using manual continuous positive airway pressure (CPAP) titration.
Case 1: A 52-year old woman was receiving treatment for severe obstructive SA and hypertension. She noticed residual drowsiness after the initiation of auto-adjusting CPAP. After manual CPAP titration, her sleepiness improved, and home blood pressure (BP) values were almost completely controlled, despite the reduced use of antihypertensives.
Case 2: A 68-year old man with chronic heart failure was receiving treatment for severe SA by means of auto-adjusting CPAP. A favorable decrease in morning BP was observed after manual CPAP titration.
Remarkable antihypertensive effects were observed in hypertensive patients with severe SA after administering individualized and optimized CPAP therapy. SA treatment that is optimized with CPAP titration should be considered as an approach for strict antihypertensive management in hypertensive SA patients.

An 83-year-old woman with end-stage renal disease (G5) received a left forearm arteriovenous (AV) shunt for vascular access 5 years before the current presentation. She had previously been hospitalized 12 times for heart failure but had not been admitted after creation of the fistula. Her renal function was maintained even with end-stage disease, and hemodialysis had been avoided. During a recent admission for heart failure treatment lasting approximately 3 weeks, an exacerbation of pulmonary hypertension (PH) was observed, and her prescriptions, including diuretics, were adjusted. Her medical condition improved, and she was discharged from the hospital under close observation. After discharge, dyspnea on effort gradually worsened. She presented again with dyspnea at rest and was readmitted for further examination and treatment for hypoxia. Transthoracic echocardiography revealed increased right ventricular systolic pressure caused by tricuspid regurgitation, suggesting exacerbation of her PH. After various examinations, we hypothesized that changes in hemodynamics resulting from the AV shunt might be affecting the onset and exacerbation of PH, so we closed the AV fistula. Right heart catheterization performed before and after shunt closure showed mean pulmonary artery pressures of 46 mmHg before closure and 37 mmHg after closure. We report a case of PH with challenging clinical management and hemodynamic changes associated with AV shunt creation.

Ulcerative colitis (UC) is a rare cause of stroke. Most such cases result from cerebral venous thrombosis, and cerebral vasculitis is one cause of venous thrombus formation. Here, we report a patient with UC who experienced recurrent cerebral hemorrhage. A 53-year-old Japanese woman with UC presented with sudden onset of disorientation and sensory aphasia. Brain computed tomography revealed cerebral hemorrhage in the left temporal lobe. She had a history of UC for two decades but had discontinued her medication. On the fifth hospital day, another cerebral hemorrhage occurred in the right occipital lobe. After steroid therapy, these abnormal findings on MRI improved within a short time, and she was discharged from hospital with no sequelae. Physicians should be alert to cerebral hemorrhage in patients with UC, consider cerebral vasculitis as an etiology, and treat with steroid therapy for a good outcome.