Background: Video analysis of body and gaze movements has recently become widespread, mainly in the field of engineering, however, few medical studies have used motion capture and eye-tracking systems. The aim of this study was to test the hypothesis that head movements and gaze distribution during tracheal intubation differ between practitioners who are expert at tracheal intubation and those who are novice at tracheal intubation as a secondary analysis of our previous study.
Methods: Practitioners who were either novices or experts at tracheal intubation using Macintosh laryngoscopes were recruited. Head movement and gaze distribution during tracheal intubation into a mannequin were recorded using motion capture and eye-tracking systems and analyzed according to 3 phases: phase A (mouth opening), B (obtaining vocal cord view), and C (tracheal intubation). The values obtained were compared between novices and experts.
Results: Intra-group comparison showed significant differences in the height of the head and forward-backward head tilt during tracheal intubation in the experts and novices, respectively. Inter-group comparison showed significant differences at each phase except for the height of the head at phase A (height: 154.1 vs. 159.1 cm, p = 0.602 for Phase A; 150.6 vs. 141.3 cm, p < 0.001 for Phase B; 151.2 vs. 135.6 cm, p < 0.001 for Phase C; tilt: 2.9 vs. 6.4 cm, p < 0.001 for Phase A; 6.5 vs. 9.3 cm, p < 0.001 for Phase B; 6.2 vs. 8.4 cm, < 0.001 for Phase C). Gaze depth analysis indicated that the experts had a further gaze distance. While the experts continued looking down throughout the tracheal intubation, the novices looked up after the mouth opening phase until the accomplishment of intubation.
Conclusion: Posture and gaze distribution during tracheal intubation with a laryngoscope differed between novices and experts. The results of this study will help trainers develop a clear teaching policy and help trainees become aware of their posture during tracheal intubation training.

Objective: Layilin is a type I transmembrane protein that possesses a C-type lectin motif in its extracellular domain, and whose functions have not yet been completely understood. Previously, we reported that layilin was highly expressed in malignant glioma cells. In this study, we investigated whether layilin was functionally related to low-density lipoprotein receptor (LDLR) in malignant glioma cells because one of the characteristics of malignant glioma cells is the high expression of LDLR.
Methods: Under layilin-knockdown (KD) conditions in A172 cells, a malignant glioma cell line, we measured LDLR mRNA and protein levels by quantitative polymerase chain reaction and western blotting, respectively. Furthermore, we measured LDL uptake in layilin-KD cells by LDL uptake assay.
Results: Even though the amounts of mRNA for LDLR were unaffected by layilin-KD, the amounts of LDLR protein were significantly increased by layilin-KD 48 h after transfection with small interfering RNAs for layilin (p<0.05). Accordingly, LDL uptake was increased by layilin-KD (p<0.05).
Conclusion: Our data suggest a novel function of layilin, that is, down-regulation of LDLR at the protein level.

ICU-acquired weakness (ICU-AW) is an acute diffuse muscle weakness that is an important prognostic factor for patients in today’s intensive care units. In this study, we created a novel ICU-AW model of sepsis in which septic rats were immobilized in a lower limb cast for 96 hours. We investigated the structural changes in muscle tissue following lipopolysaccharide (LPS)-induced inflammation and cast immobilization from a pathological viewpoint. Ten-week-old male rats were divided into four groups: control group (C-group, n=6), cast-immobilized group (CC-group, n=6), LPS administration group (L-group, n=6), and LPS administered and cast immobilized group (LC-group, n=6). The LPS administration time and dose were determined based on the results of a study experiment performed first. After the LPS administration/cast-immobilization experiment, body weights and wet weights of both isolated soleus muscles were measured. Muscle tissue was analyzed from a pathological perspective using optical and transmission electron microscopy. Although the comparison of body weights between the four groups showed no significant differences after 96 h, a severe loss of soleus muscle wet weight and decrease in the relative soleus weight ratio were observed in the LC-group. Optical microscopy results showed that a significant increase in cross-sectional area (CSA) and decrease in the average number of muscle fibers were observed in the LC-group compared with all other groups (p<0.05), and the CSA showed a mixture of small and large muscle fibers. The average number of vacuoles in muscle fibers appeared to be significantly increased in the CC and LC-groups (p<0.05, vs. the C, L-group). Longitudinal electron microscopic images showed distorted sarcomeres, Z-band disruption, and loss of actin-myosin filaments was present in the cross-sections. The present study suggested that from a pathological viewpoint, a combination of inflammation and immobilization causes more severe consequences in terms of structural changes in muscle tissue than either factor alone.

[Background/Objective] We assessed trends in serum nutritional status markers and body mass index (BMI) to evaluate the long-term nutritional status in patients with pylorus-preserving pancreatoduodenectomy (PPPD).
[Methods] From 240 patients who underwent PD from January 2005 to October 2014, we selected 45 patients who underwent PPPD and had survived without recurrence at 5-year postoperative follow-up. The following factors were analyzed preoperatively and at 2 weeks, and 1, 5 years, postoperatively: serum total protein (TP), serum albumin (Alb), and body mass index (BMI).
[Results] The mean TP value was 6.8 g/dL preoperatively and 6.3 and 7.1 g/dL at 2 weeks and 1 year after surgery, respectively (P<0.0001, P=0.026, respectively). TP remained greater than the preoperative values for up to 5 years. The mean Alb value was 4.1 g/dL preoperatively, decreased to 3.5 g/dL 2 weeks after surgery, but returned to 4.15 g/dL 1 year after surgery and to 4.13 g/dL 5 years after surgery, values approximately equivalent to the preoperative value (P=0.134, P=0.505, respectively). The mean preoperative BMI was 22.1 kg/m², decreased to 17.3 kg/m² 2 weeks after surgery (P<0.001), and then rose to 19.0 kg/m² by 5 years after surgery (P=0.005), but remained within the standard range in 29 patients (64.4%).
[Conclusion] Long-term nutritional status was adequately maintained postoperatively in patients who underwent PPPD.

Objective: Dysphagia occurring after surgery to treat thoracic esophageal cancer is commonly believed to be caused by recurrent laryngeal nerve (RLN) paralysis and injury to the muscles involved in swallowing due to manipulation during cervical lymph node dissection. However, we previously performed studies in our department and reported that RLN paralysis and dysphagia are not necessarily related. We also found that geniohyoid muscle atrophy, which occurs due to perioperative fasting, may also cause dysphagia. Meanwhile, some reports have documented a relationship between dysphagia and decreased laryngeal elevation distance (LED) during videofluorography (VF) in elderly patients and after esophageal cancer surgery. There are few published reports of a relationship between dysphagia and changes in the LED that have compared pre- and postoperative VF findings. We therefore performed a study of the relationship between the incidence of dysphagia and changes in pre- and postoperative LED.
Method and Results: The subjects of the present study were 72 patients who underwent surgery to treat thoracic esophageal cancer in our department from April 2014 to March 2020. All patients underwent pre- and postoperative VF, during which we measured the LED. We divided them into an aspiration (A) group of 17 patients and a non-aspiration (NA) group of 55 patients. The difference between the pre- and postoperative LED values was 14.12 ± 5.67 mm in the A group, which was significantly larger than the NA group value (8.63 ± 4.83 mm, P = 0.0002). The rate of change in the LED was significantly greater in the A group at 45.72 ± 15.69%, compared with 31.69 ± 14.67% in the NA group (P = 0.0011).
Conclusion: There was a significant decrease in LED among patients presenting with postoperative dysphagia after esophageal cancer surgery, suggesting that LED measurement may be a useful quantitative indicator assessable during VF.

[Purpose] This study aimed to determine an optimal method for estimating adult hernial orifice diameter using computed tomography (CT) performed with the patient in the prone position to achieve inguinal decompression of the hernia (CT hernia study).
[Methods] Fifty-four adult patients with inguinal hernia underwent laparoscopic hernia repair by transabdominal preperitoneal patch technique. Before surgical manipulation, we measured actual hernial orifice diameters in these patients. All patients underwent surgery after the CT hernia study became the standardized form of preoperative imaging for adult inguinal hernia patients in 2006 at St. Marianna University Hospital. We calculated the estimated hernial orifice diameter using four formulas for external inguinal hernias (Type I) and two formulas for internal inguinal hernias (Type II). Then, based on the preoperative images, a linear univariate regression model was created for the four type I estimation formulas by defining the estimated values as explanatory variables (X) and the actual hernial orifice diameters as objective variables (Y).
[Results] A significantly positive correlation was observed between all estimation models using preoperative diagnostic imaging and actual hernia diameter measurements in the adult patients. The most effective formulas were the estimation method mimicking 3D imaging (length of a line connecting the medial pole of the inferior epigastric artery and internal margin of the external iliac artery in the same transverse image) for type I hernias and the sagittal image method (maximum length of a line connecting the superior and inferior ends of the hernia sac [intraperitoneal tissues] projecting outside the transversalis fascia line in a sagittal image) for type II hernias.
[Conclusion] CT hernia studies that mimic 3D reconstruction in type I hernias and use sagittal images for type II hernias may be a useful method for estimating hernial orifice diameters in adult patients.

During the first stage of clinical internship at St. Marianna University Hospital, we believe that it is important to conscientiously consider the “process of reflection” and consolidate the growth trajectory and outcomes. This led to the introduction of portfolios in 2003 that considers the medical interns and their instruction to be a single unit, allows them to establish objectives, and facilitates their reflection of their own behavior. Our subjects were 43 interns who started the internship program at St. Marianna University Hospital in 2012 and underwent the Final Internship Evaluation after completing the first stage of internship in March 2014. The new Final Internship Evaluation criteria (rubric) included six evaluation perspectives. An evaluation scale was created to grade each question on a scale of 1 to 5. In addition, the valuation was also performed using the conventional method, which included 15 criteria, to investigate correlation between the portfolio evaluation method and the conventional evaluation method. Five points could be scored in total for a single item, thus allowing interns to attain a total score of 75 points. The mean evaluation score given by the two instructors using the new evaluation method was 4.4 points, whereas that given using the conventional method was 57.1 points. The performance rankings obtained with the old and new evaluation methods were similar, and a positive correlation was observed between the two (correlation coefficient: 0.69). The grades awarded after using the new and old evaluation methods were similar even though the evaluation perspectives in these two methods differed, so it would be desirable to perform an evaluation that combines elements of both methods.

Background: Our previous reports demonstrated that antenatal glucocorticoid (GC) administration increased cardiomyocyte proliferation in preterm fetuses, leading to the maturation of the heart. Understanding the proliferative mechanisms of fetal cardiomyocytes might be applicable to regenerative therapeutic strategies. In this study, we investigated whether antenatal GC administration affects Yes-associated protein (Yap), a transcriptional activator of cardiomyocyte proliferation.
Methods and Results: Eight-week-old pregnant Wistar rats were administered dexamethasone for 2 consecutive days between gestational days 17 and 21 before cesarean section. The production of the proliferation markers, cyclin D1, Ki-67, and Yap in the nuclei of cardiomyocytes was analyzed using immunohistochemistry. To clarify the relationship between upstream factors and Yap, we evaluated the expression of agrin, an extracellular matrix protein, using Western blot analysis. Although cyclin D1-, Ki-67-, and Yap-positive cells gradually decreased from the fetal to neonatal stage, they increased significantly in the epicardium of 19-day fetal groups with antenatal GC administration. Agrin was also significantly increased in fetal hearts in the GC group.
Conclusions: These results suggest that antenatal GC administration affects cell proliferation in the fetal epicardium, and the increased agrin and Yap activation may be involved.

Background: The rapid response system (RRS) aims to prevent unexpected cardiac arrest by responding to the deteriorating condition of hospitalized patients at an early stage. In this study, we evaluated the status of the RRS 5 years after its introduction in St. Marianna University School of Medicine Hospital.
Methods: We retrospectively analyzed the medical emergency team (MET) request data of our hospital for the period of June 2010–May 2015. We compared the status of the RRS before and after the introduction of the critical care outreach team (CCOT) in August 2014.
Results: There were 197 MET requests over the five-year period, with an increasing trend in the number of requests. Acute altered mental status was the most common reason for MET activation, followed by oxygen desaturation (measured by a pulse oximeter) < 90%, hypotension (blood pressure <90 mmHg), and cardiopulmonary arrest (CPA). The general ward requested the MET most frequently (62.9%). Overall, 47.7% of MET-activated patients were transferred to intensive care unit, and 21.3 % were “non-transfer” cases. MET activation by general wards (55.6% vs. 78.1%, P=0.0017) and MET activation by CPA significantly increased (9.0% vs. 29.7%, P=0.0003) after the introduction of the CCOT, while the one-month survival/survival-to-hospital discharge rate significantly decreased (75.2% vs. 57.8%, P=0.0143).
Discussion and Conclusion: Over the 5 years, the number of MET requests increased, especially after the introduction of the CCOT. When RRS was required due to cardiopulmonary arrest, the patient’s condition had already deteriorated, and this was considered to have reduced the survival rate of RRS-activated patients. Comparing the data before and after the introduction of CCOT showed results different from the expected effect of RRS, probably because the RRS is usually triggered after a patient’s condition clearly deteriorates. In the case of a cardiopulmonary arrest, when the patient’s condition had already deteriorated and the number of CPA-related requests increased, a decrease in the survival rate was considered. Therefore, efforts must be made to request MET at an earlier stage and to use the Code Blue System to enable an earlier response for cases of cardiopulmonary arrest.

Urinary tract infection (UTI) is one of the most common clinical diagnoses managed by primary care physicians both in outpatient and inpatient care. The increasing ratio of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) among UTI-causing pathogens is an epidemiological concern both in Japan and worldwide, leading to a higher empirical usage of broad-spectrum antibiotics. Commercially available genotypic diagnostic technologies for ESBL-E have been incorporated in clinical settings to facilitate earlier de-escalation to narrow-spectrum antibiotics. However, genotypic testing can detect only certain genotypes of the ESBL (CTX-M) group, and there are insufficient data regarding the ratio of other ESBL genotypes (TEM, SHV), especially in severe UTI cases. In this study, we collected consecutive ESBL-E isolates from UTI cases that fulfilled the systemic inflammatory response syndrome (SIRS) criteria from June 2012 to July 2017 in a tertiary metropolitan hospital in Japan and evaluated their genotypic distribution. Among 36 isolates, the number of cases with genotypes CTX-M-1, CTX-M-2, CTX-M-9, SHV, and TEM were 12, 4, 21, 1, and 14, respectively. Notably, all isolates with SHV and/or TEM genotypes concomitantly had one of the CTX-M genotypes, and there were no ESBL-E isolates that harbored only SHV or TEM. Further research is warranted to investigate the utility of commercially available genotypic diagnostic technologies for ESBL-E in the clinical setting.

With the development of direct-acting antiviral (DAA) treatment for chronic hepatitis C including liver cirrhosis (type C chronic liver disease; type C CLD), almost 100% virus elimination can be achieved. DAA treatment is also being expanded for elderly patients and/or patients with advanced fibrosis. Therefore, there is a concern that the risk of hepatocellular carcinoma (HCC) after DAA treatment may increase. We examined the current status of HCC occurrence in 241 patients who achieved a sustained virologic response (SVR) upon DAA treatment for type C CLD with no history of liver cancer. HCC was developed in 12 patients (5.0%), and the cumulative incidence rate was 1.3% for 1 year, 3.1% for 2 years, 3.6% for 3 years, 4.7% for 4 years, and 6.4% for 5 years, respectively. Moreover, the rate of HCC incidence was significantly higher in elderly patients (≧70 years old; P=0.0488). Nine cases were diagnosed as HCC stages I and II, and the prognosis was favorable with proper treatment. The remaining three cases were suspected to rapidly progress toward advanced HCC, diagnosed as stage III and IV at the time of diagnosis; all the patients died within a year. Consequently, post-SVR HCC occurrence after DAA treatment should be carefully followed on a case-by-case basis, especially in the elderly and in patients with advanced fibrosis.

Background: Psoriasis, a chronic inflammatory skin disease, has a high prevalence of metabolic syndrome. The fat stored in obese people tends to be proinflammatory, however, certain fatty acids such as short-chain fatty acids are anti-inflammatory. Although short-chain fatty acids are known to attenuate inflammation in several diseases, the effect of short-chain fatty acids, such as β-hydroxybutyrate, on psoriasis remains unknown.
Objectives: To investigate the role of β-hydroxybutyrate in psoriasis.
Materials and Methods: Several short-chain fatty acids, such as acetic acid, propionic acid, butyric acid, and β-hydroxybutyrate were administered to murine imiquimod-induced psoriasis-like skin inflammation. The clinical score was evaluated through the course of this treatment and the number of infiltrating neutrophils was counted. The expression of inflammatory cytokines such as tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-17 in skin tissues was measured by quantitative reverse transcription polymerase chain reaction (RT-PCR). In addition, β-hydroxybutyrate was added to IL-17-stimulated HaCaT cells and the expression of inflammatory cytokines and receptors for β-hydroxybutyrate were measured.
Results: β-Hydroxybutyrate significantly improved skin symptoms and attenuated neutrophilic infiltration. β-Hydroxybutyrate also reduced the expression of inflammatory cytokines such as TNF-α, IL-1β, and IL-17. In addition, β-hydroxybutyrate reduced the expression of TNF-α and IL-1β in IL-17-stimulated HaCaT cells.
Conclusion: These results suggest that β-hydroxybutyrate reduces psoriasiform dermatitis and it may act directly on keratinocytes to reduce inflammation.

Bilateral anterior shoulder dislocation is a relatively rare condition. In a patient presenting with bilateral shoulder pain, a posteroanterior radiograph of the shoulders easily reveals the diagnosis. A 76-year-old woman presented to our emergency room with complaints of bilateral shoulder pain. She had fallen forward with both elbows hitting the ground and also hit her right shoulder. A posteroanterior radiograph revealed a right anterior shoulder dislocation with no remarkable changes noted on the left shoulder. The right shoulder dislocation was resolved, and she was sent home. Six hours later, she was brought back to our emergency room with left shoulder pain. A repeat posteroanterior radiograph of the left shoulder revealed left shoulder dislocation. Bilateral anterior shoulder dislocation occurring after 6 hours is an extremely rare condition. We report this case with a review of the literature.

A 51-year-old woman underwent a CT scan performed that revealed a neoplastic lesion in the upper abdomen, and she was referred to our surgical department. Abdominal CT showed a tumor of about 50 mm lying between the posterior wall of the gastric minor curvature and the pancreas. Continuity with the surrounding tissue was not clear. Ultrasonography showed that the tumor was mobile on postural change, and it was considered to originate from the mesentery. In addition, PET scanning showed mild accumulation, and MRI showed limited diffusion, suggesting the possibility of malignancy. Laparoscopic tumor resection was performed as a diagnostic treatment. Intraoperative findings showed tumor continuity only with the lesser omentum, and the patient was judged to have a primary tumor of the lesser omentum. Histopathological findings showed proliferation of myofibroblasts and lymphocyte infiltration, and the patient was thus diagnosed as having an inflammatory myofibroblastic tumor. Inflammatory myofibroblastic tumor as a primary tumor of the lesser omentum is rare and is reported here along with a literature review.