Introduction: This study aimed to develop an oral bleeding risk scoring system (OBRS) for predicting the post-tooth-extraction bleeding risk in patients medicated with warfarin.

Materials and Methods: We included a derivation cohort of 211 consecutive inpatients from April 1, 2013 to March 31, 2015 and a validation cohort of 63 consecutive inpatients from April 1, 2015 to March 31, 2016 who underwent tooth extraction at Tokyo Women's Medical University hospital. Post-tooth-extraction bleeding was observed in 29 (13.7%) cases in the derivation cohort. Using multivariate logistic analysis, three predictors (international normalized ratio of prothrombin time: PT-INR, drugs, incision) were selected for the final model.

Results: OBRS was derived as follows: PT-INR×2+drugs+incision. Receiver operating characteristic curves provided area under the curve of 0.77 (95%CI, 0.67 to 0.85) for OBRS, 0.61 (95% CI, 0.50 to 0.71) for HAS-BLED score, and 0.69 (95% CI, 0.56 to 0.79) for PT-INR. The high-risk cut-off OBRS value was 5.08 points. Post-tooth-extraction bleeding was observed in 9 (14.2%) cases in the validation cohort. Sensitivity and specificity were 100% and 90.7%, respectively. The OBRS showed excellent performance with respect to predictor score.

Conculusions: The proposed OBRS showed good performance for predicting post-tooth extraction bleeding in patients undergoing warfarin treatment.

Aim: Sodium-glucose cotransporter 2 inhibitors are novel antidiabetic agents that inhibit glucose reabsorption in the renal proximal tubules. We assessed the potential effects of sodium-glucose cotransporter 2 inhibitors on body weight, hepatic fat accumulation, and liver stiffness by using transient elastography (TE) and measuring biochemical markers associated with nonalcoholic fatty liver disease (NAFLD) with type 2 diabetes mellitus (T2DM).

Methods: For 12 weeks, patients with T2DM and NAFLD were treated by ipragliflozin as an add-on medication. Physical findings, biochemical blood and urinary analyses, meal tolerance test, and TE were assessed before and 12 weeks after the administration of ipragliflozin.

Results: Fifteen patients were enrolled in this study. From baseline to 12 weeks, body mass index (BMI; p < 0.0001), hemoglobin A1c (p < 0.01), and fasting and postprandial plasma glucose (p < 0.05 and p < 0.01, respectively) were significantly reduced. Fasting C-peptide immunoreactivity index (p < 0.05), urinary glucose (p < 0.001), and hematocrit (p < 0.01) were significantly increased. Uric acid (p < 0.01), γ-glutamyl transpeptidase (p < 0.05), ferritin (p < 0.001), hepatic fat accumulation (i.e., the controlled attenuation parameter [CAP]; p < 0.05), and liver stiffness (E; p < 0.05) were significantly decreased, as measured by TE. The percent change in BMI and the change in the aspartate aminotransferase, alanine aminotransferase (ΔALT), and type IV collagen 7s levels, and in the aspartate aminotransferase-to-platelet ratio index and fibrosis-4 index values were correlated with the change in the CAP (ΔCAP). The ΔALT was the only independent predictor of ΔCAP, based on multivariate analysis (p < 0.01).

Conclusions: The administration of the sodium-glucose cotransporter 2 inhibitor ipragliflozin may be associated with the amelioration of hepatic steatosis and elasticity in patients with T2DM and NAFLD.

We conducted a nationwide questionnaire survey of 500 randomly sampled municipalities to calculate the public-funded human papilloma virus (HPV) vaccination rates in fiscal years 2011-2013. The characteristics of different municipalities were determined from the national statistical data, including those for all the municipalities in Japan. Based on the questionnaire results, we divided the fiscal 2012 HPV vaccination rate into two groups using the median value as the threshold: objective variable and municipality characteristics (29 items) as explanatory variables. Univariate and multivariate regression analyses were performed using the Akaike Information Criterion (AIC) scoring system to examine the valid explanatory variables. Univariate analysis of data from 150 municipalities indicated that the model was good because among 29 explanatory variables, AIC values were the lowest for "number of kindergartens" (AIC: -22.35), followed by "population" (AIC: -11.32), and the two-dimensional cross tables suggested that these explanatory variables were negatively correlated with HPV vaccination rates. Multivariate analysis showed that the combination of "number of kindergartens" and "number of households" (AIC: -30.29) had the smallest AIC values and were the optimal model for explaining HPV vaccination rates in local municipalities. The predictors for improved HPV vaccination rates suggested that these rates were high in municipalities characterized by a small population, large proportion of the elderly, and increased financial stability.

Lung air-leak (LAL) is an unavoidable complication after thoracoscopic lung resections. Generally postoperative LALs are managed with a digital low-pressure continuous suction device (DCSD) with three bottles. Since the management is performed by information obtained visually, sharing the data among medical staff becomes difficult, resulting in an issue. Fourteen consecutive surgical cases underwent thoracoscopic lung wedge resection. Intraoperative LALs were detected in 6 patients. Immediately after surgery, as postoperative management, a DCSD was used. Postoperative LALs were found in 12 cases; the periods of drainage were 2 to 15 days with a mean of 5.0 ± 3.6 days. Twelve hours' air-bubble time before clamp test was 0.01 - 2.29 s/60 s with a mean of 0.74 ± 1.12 s/60 s. After clamp test, lung collapse identified by chest X-ray examination was found in 2 cases, and in 1 case, lung collapse was caused by sucking air through the inserting port of drain tube without LAL. In medical staff conference, necessary information was shared by using a large liquid crystal display.

Purposes: Whether hepatectomy is justified in patients with hepatocellular carcinoma (HCC) on hemodialysis (HD) for end-stage renal disease (ESRD) is unclear. This study evaluated clinical characteristics and outcomes in patients with HCC on HD for ESRD who underwent hepatectomy.

Methods: Hepatectomy was performed in 17 patients in an ESRD group and 181 in a non-ESRD group. We compared clinical characteristics and outcomes between these groups.

Results: Compared with the non-ESRD group, the ESRD group had a significantly higher rate of diabetes mellitus, higher serum creatinine levels, lower levels of hemoglobin, aspartate aminotransferase, and alanine aminotransferase, and a lower indocyanine green retention rate at 15 min. There were no significant differences between the 2 groups in other clinical characteristics, laboratory data, surgical outcomes, pathological findings, or overall postoperative morbidity or mortality. However, the incidence of postoperative pneumonia, gastrointestinal bleeding, and intra-abdominal bleeding was significantly higher in the ESRD group. The 5-year disease-free survival rate was 44.3% in the ESRD group and 24.0% in the non-ESRD group (p=0.4483), and the 5-year survival rates were 76.4% and 65.1% (p=0.2291), respectively. HD and serum creatinine levels were not significant prognostic factors for survival and recurrence.

Conclusion: Hepatectomy for HCC in patients with ESRD on HD may be associated with increased risk of postoperative pneumonia, gastrointestinal bleeding, and intra-abdominal bleeding, but is feasible if careful surgical and perioperative management are provided.

Background: Past clinical studies have shown the relationship between type 2 diabetes (T2D) and obstructive sleep apnoea (OSA), but little is known about type 1 diabetes (T1D). The purpose of this study is to examine clinical indicators associated with OSA in patients with different subtypes of diabetes.

Methods: Self-administered questionnaires that asked if the patients had been diagnosed with OSA were distributed to patients with T1D and T2D. General and clinical information was confirmed with both questionnaires and medical records.

Result: Among the 1,269 T1D patients and 5,838 T2D patients, 20 T1D patients and 421 T2D patients had received a diagnosis of OSA. OSA patients were more likely to be male, older, and to have a greater BMI and lower LDLC and HDLC. T1D patients with OSA were characterized by a significantly higher prevalence of severe hypoglycemia. On the other hand, T2D patients with OSA had high HbA1c, decreased renal function, high frequency of diabetic neuropathy, and correlated with macrovascular complications.

Conclusion: The prevalence of OSA was significantly higher in T2D patients. It was suggested that OSA-related pathologies might differ between T1D and T2D patients.

Background: In pediatric intensive care, temperature management is very important and requires precise monitoring. The new zero-heat-flux cutaneous thermometer (SpotOn™) has been introduced as a measurement tool with good correlation to core body temperature. The aim of this study is to evaluate the accuracy of SpotOn™ in pediatric intensive care unit (ICU) patients.

Methods: Critically ill pediatric patients weighing less than 10 kg were included in this study. After admission to the ICU, core body temperature was measured with both the SpotOn™ system and a rectal thermistor and recorded at one-minute intervals.

Results: From 30 patients, 53,492 pairs of temperature data were collected and analyzed retrospectively. The median age and weight of the patients were 4.5 months and 5.6 kg, respectively. SpotOn™ showed a good correlation with measured rectal temperature, with a Pearson's correlation coefficient of 0.729 (p<0.001). However, a Bland-Altman analysis showed that the SpotOn™ bias in comparison to rectal temperature was +0.87°C (SD: 0.51°C), and the 95% limits of agreement (LOA) were −0.14°C and 1.83°C.

Conclusions: The SpotOn™ system has a low level of accuracy as a method of monitoring core body temperature in pediatric patients weighing less than 10 kg.

Background: Gastric leiomyomas are usually solitary, rounded, and demarcated masses, and multiple leiomyomas (more than three) are extremely rare. We report a case of a 30-year-old woman who was referred to our hospital for further treatment of an enlarging gastric submucosal tumour (SMT).

Case Presentation: She underwent laparoscopic gastric partial resection with oesophagogastroduodenoscopy (OGD), which revealed a multinodular gastric SMT (10 cm in diameter) located in the upper body of the stomach. Endoscopic ultrasonography (EUS) revealed a hypoechoic mass located in the fourth layer and multiple nodules approximately 1 cm in diameter. We subsequently performed EUS-guided fine-needle aspiration biopsy. The patient underwent laparoscopic gastric partial resection with EGD. Because the tumour was extensive on the lesser curvature of the stomach and was located near the oesophagogastric junction, we preserved the gastric function with minimal resection of the stomach. No intraoperative or postoperative complications were observed. The tumour was pathologically diagnosed as gastric leiomyoma. Laparoscopic minimized resection used by endoscope, can avoid gastric deformity and preserve gastric function, especially when the gastric SMTs are located near the oesophagogastric junction.

Conclusion: Laparoscopic gastric partial resection with EGD is an effective treatment option for complete resection of extensive gastric SMT.

Although intestinal obstruction is a relatively common condition to be seen in daily clinical practice, cases with no history of laparotomy can often create difficulties in determining its diagnosis and surgical indication. This is a case report of a recurrent intestinal obstruction, with no surgical history, treated successfully using laparoscopy for both diagnosis and surgical operation.

The patient, 62-year-old male, was hospitalized about a year ago due to abdominal pain and diarrhea likely caused by acute enteritis. As the inflammation had reduced and X-Ray image no longer indicated any gas patterns in the small intestine, he was later discharged from the hospital. However, the symptoms recurred after seven months which included abdominal pain, diarrhea as well as bloating. The patient was then introduced to our hospital through a local clinic for further diagnosis.

The results resembled patient's previous hospitalization observing a formation of niveau, or mirror-image, in the upper abdomen as well as a sentinel loop with some swelling on computed tomography (CT) image. With conservative treatment, the patient showed rather a quick recovery soon after his admission. The inflammation and the intestinal obstruction had reduced. However, as recurrence had appeared in a similar area as his previous experience, the patient underwent diagnostic laparoscopy for further inspection of its underlying cause.

Adhesion of the ileum and the sigmoid colon was observed. After diagnosis, laparoscopic adhesiolysis was performed in order to divide the adhesion and to remove the inflated part of the small intestine. The postoperative course was positive and the patient was discharged from the hospital 13 days after the surgery. There has been no report of recurrence thereafter.

Technological development of CT scanners in recent years has enabled new levels of information. However, cases with no surgical history and fluctuating symptoms, such as the patient mentioned in this paper, requires direct observation of the tract. Doing so also helps determine the possibility of an internal hernia. Furthermore, laparoscopy enables a smooth shift from diagnosis to treatment, with the assistance of laparoscope, which avoids unnecessary invasion and requires only small incisions; serving it as a very effective approach to certain cases of intestinal obstruction.

Meigs' syndrome (MS) is defined as a benign ovarian tumor with pleural effusion and ascites, which, resolve after its removal. The pathogenesis of ascites and pleural effusion in MS is unknown. A 64-year-old woman with a history of uterine fibroid was admitted owing to dyspnea over 1 month. A chest radiograph showed right hydrothorax. Carbohydrate antigen 125 (CA-125) level was 645 U/mL. Computed tomography of chest, abdominal, and pelvis showed hydrothorax in the right thoracic cavity and atelectasis of the right lower lobe, a tumor, 14 cm in diameter, and ascites in the pelvis. Despite chest drainage for hydrothorax, the amount of pleural effusion was over 300 ml/days every day. Pleural fluid was a lymphocyte-predominant exudate. The bacterial mycobacterial cultures of the pleural fluid were negative. Cytological examination of the pleural fluid showed no malignancy. As the combination of pleural effusion, ascites, and ovarian tumor was suggestive of MS, the patient was referred to the Department of Gynecology. She underwent total hysterectomy and bilateral salpingo-oophorectomy. Histopathological examination of the resected tumor confirmed fibrothecoma. Thus, it is important to consider the possibility of MS in female patients with unexplained pleural effusion and an ovarian tumor.

Pyridoxine-dependent epilepsy (PDE) is an inherited disease with an autosomal recessive trait caused by deficiency of α-amino-adipic semialdehyde (AASA) dehydrogenase encoded by the ALDH7A1 gene. Pyridoxine administration is usually effective for the treatment of PDE. We identified compound heterozygous ALDH7A1 mutation in a patient with undiagnosed intractable epilepsy. One of the mutations was located in the splicing region of this gene. We analyzed the RNA expression patterns and confirmed the hemi-allelic expression of this gene, which could be considered a consequence of erroneous splicing, though this was not direct evidence of a splicing error. The severe developmental delay observed in this patient could have been avoidable by prompt treatment intervention in the early neonatal period. Therefore, it is important to remind that vitamin B6 should be prescribed for neonatal patients with clustering seizures occurring soon after birth.

Lenvatinib is a molecular targeted drug used in the treatment of patients with unresectable thyroid cancer. We present a case of medication-related osteonecrosis of the jaw (MRONJ), which occurred in a patient receiving lenvatinib therapy and which was treated by surgical management. The objectives of this paper are to highlight the possibility of MRONJ being associated with lenvatinib and to accumulate knowledge regarding the management and treatment of MRONJ associated with antiangiogenic drugs. The patient's past medical history included thyroid follicular carcinoma with multiple bone metastasis diagnosed in 2013. Lenvatinib was used on the patient in July 2015 for the treatment of thyroid follicular carcinoma. Three months after the start of the lenvatinib drug holiday, a sequestrectomy involving the extraction of the lower right canine and upper left first premolar was performed under general anesthesia. The patient maintained lenvatinib therapy and when a follow-up was made five months after sequestrectomy, the wound showed complete mucosal healing. Levatinib is related to MRONJ and its developmental mechanism might be caused by inhibition of angiogenesis targeting vascular endothelial growth factor receptor.