Journal of Nippon Medical School最新文献

Rosai-Dorfman disease (RDD), which was first reported by Rosai and Dorfman in 1969, is a rare, benign, non-neoplastic proliferation of histiocytes, characterized by painless lymphadenopathy and fever. Lymphadenopathy occurs most commonly in the neck, but also appears in non-cervical lymph nodes or as extranodal lesions. In this case, biopsy of an atypical subcutaneous buccal mass, which was difficult to diagnose preoperatively, led to a diagnosis of RDD. In addition, although lesions were also confirmed in the maxilla, none of the lesions were in lymph nodes; therefore, we ultimately diagnosed the patient with extranodal RDD (ENRDD). Compared with classical RDD, characterized by painless lymphadenopathy and fever, ENRDD is observed only in soft tissue and bone, and occurs mostly frequently among older adults. Cases presenting with lymph node or vital organ lesions also present with systemic symptoms, usually with a progressive and sometimes fatal course. However, RDD localized in soft tissue and bone has a favorable prognosis, and follow-up alone is considered sufficient. Although this case featured epidemiological characteristics of ENRDD, and as there are no fixed therapeutic guidelines, the recommendation is that treatment be considered on a case-by-case basis according to the site and symptoms. There are few reports of ENRDD; therefore, we aim to contribute the details of an additional case to the literature.

Background: Postoperative bleeding is a potentially life-threatening complication following thyroidectomy, but the risk factors and timing remain insufficiently understood. The bleeding rate for endoscopic surgery, specifically video-assisted neck surgery (VANS), also remains unclear in Japan.

Methods: We conducted a retrospective case-control study of postoperative bleeding requiring readmission to the operating room.

Results: The overall postoperative bleeding rate was 1.85%. Multivariate analysis revealed that postoperative bleeding was independently associated with antithrombotic therapy (odds ratio 2.95; 95% confidence interval 1.15-7.59) and dialysis (odds ratio 6.53; 95% confidence interval 1.75-24.2). Among patients with postoperative bleeding, the complication developed within 6 h in 56.1% and within 24 h in 93.0%. The postoperative bleeding rate in endoscopic surgery was 1.6%. The most common site of bleeding was around the thyroid in conventional surgery and around the flap in endoscopic surgery.

Conclusions: Post-thyroidectomy bleeding is associated with antithrombotic therapy or dialysis. While the bleeding rate in endoscopic surgery is similar to that in conventional surgery, the bleeding site differs.

Background: Detective flow imaging (DFI) is a new imaging technology that displays low-velocity blood flow, which is difficult to visualize on conventional color Doppler ultrasonography (CDU). In this study, we compared the usefulness of DFI with that of CDU and methoxy-isobutyl-isonitrile (MIBI) scintigraphy for detecting parathyroid adenoma (PA) in patients with primary hyperparathyroidism (PHPT).

Methods: From March 2021 to March 2023, 87 PHPT patients underwent surgery, and 66 had a single PA. We performed preoperative conventional ultrasonography with CDU, MIBI scintigraphy, and DFI for 42 patients (5 males and 37 females; mean age: 61.6 ± 15.4 years).

Results: MIBI scintigraphy detected PA in 85.7% (36/42) patients, and both CDU and DFI detected PA in all patients. The rates of vascularity in PA detected by CDU and DFI were 71.4% (30/42) and 85.7% (36/42), respectively. Vascularity was detected by DFI in 6 patients who were negative for vascularity on MIBI scintigraphy. Furthermore, DFI detected blood supply in 6 of the 12 patients with undetectable blood supply on CDU. Fisher's exact test revealed that high or low blood flow, as determined by DFI, was significantly associated with detection of feeding vessels in PA by CDU (P < 0.001).

Conclusions: DFI was useful for preoperative detection of PA blood flow.

Background: Antipsychotics are commonly used to treat delirium but can adversely affect the extrapyramidal and cardiac conduction systems. Antipsychotic use has also been reported to be associated with increased mortality in older adults. Therefore, alternative and adjunct medications for delirium are necessary. We retrospectively assessed the efficacy and safety of gabapentin (GBP) as an alternative and adjunct medication for delirium.

Methods: We retrospectively investigated the records of patients with delirium treated with GBP (71 patients; median age, 81 years; interquartile range, 76-87.5 years; 54.9% males) at a general hospital. We examined duration to delirium improvement, as assessed by the Intensive Care Delirium Screening Checklist (ICDSC) and DSM-5 criteria, as well as adverse events.

Results: The median (interquartile range) GBP dose was 200 mg (150-350 mg) /day. A total of 71.8% and 85.9% of the patients failed to meet the diagnostic criteria for delirium at 2 days and 5 days after initial administration, respectively (p<0.05). In subgroup analysis, patients with a history of epilepsy or cerebrovascular disease responded better to GBP than did those without such histories, suggesting that patients with abnormal/borderline neuronal activity respond to GBP even though they do not exhibit seizures. GBP did not induce extrapyramidal symptoms, cardiac conduction disturbances, hyperglycemia, or epilepsy but caused sleepiness and myoclonus.

Conclusions: GBP may improve delirium with fewer adverse effects and may be a safe alternative or adjunct treatment for delirium. Dosage adjustment may be necessary to prevent sleepiness.

Background: The Japanese Society for Pharmaceutical Palliative Care and Sciences specializes in pharmacology in the field of palliative medicine. More than 700 board-certified pharmacists in palliative pharmacy (BCPPP) are actively involved in palliative pharmacotherapy at various hospitals and pharmacies. The purpose of this study was to determine the economic effect of pharmaceutical interventions by BCPPPs.

Methods: This multicenter retrospective study included 27 medical centers and analyzed the medical economic effect of interventions by BCPPPs (17 pharmacists) and non-BCPPPs (24 pharmacists) on patients using medical narcotics for cancer pain in September 2021.

Results: The percentage of patients who received a pharmaceutical intervention and whose drug costs were reduced by pharmacist intervention was significantly higher in the BCPPP group than in the non-BCPPP group. Although there was no significant difference between the two groups in drug cost reduction per patient per month (BCPPP group: $0.89 [-$64.91 to $106.76] vs. non-BCPPP group $0.00 [-$1,828.95 to $25.82]; P = 0.730), the medical economic benefit of pharmacist intervention in avoiding or reducing adverse drug reactions was higher in the BCPPP group ($103.18 [$0.00 to $628.03]) than in the non-BCPPP group ($0.00 [$0.00 to $628.03]) (P = 0.070). The total medical economic benefit-the sum of these-was significantly higher in the BCPPP group ($88.82 [-$14.62 to $705.37]) than in the non-BCPPP group ($0.66 [-$1,200.93 to $269.61]) (P = 0.006).

Conclusion: Pharmacological intervention for patients with cancer using medical narcotics may have a greater medical economic benefit when managed by BCPPPs than by non-certified pharmacists in Japan.

The abdominal wall is an uncommon site for endometriosis that occurs in the soft tissues of the wound site after laparotomy. The present study reviewed cases of post-cesarean section abdominal wall endometriosis that were surgically treated at our institution from April 2007 to August 2020. We analyzed data from nine patients who were diagnosed with abdominal wall endometriosis and selected surgery after receiving sufficient explanation of hormone therapy and from patients who reported no improvement in symptoms with hormone therapy. Written consent for case reporting was obtained from all patients. The location of abdominal wall endometriosis was at the wound site in seven cases and outside the wound in two cases. In addition, 7/9 (78%) of post-cesarean cases of abdominal wall endometriosis were related to the cesarean procedure, and 6/9 (67%) of the cases had symptoms related to menstruation. Post-cesarean abdominal endometriosis was associated with pain (7/9; 78%) and a palpable mass (3/9; 33%). Surgical resection did not cause large tissue defects, and artificial repairs such as synthetic mesh were not required for any patient. In conclusion, women with a history of a cesarean section who present with recurrent pain or masses in the wound or abdominal wall that coincide with the menstrual cycle should be closely evaluated for abdominal wall endometriosis. Because surgical treatment often requires postoperative wound reconstruction, collaboration with plastic surgeons and dermatologists is essential.

Background: Although immunohistochemical techniques and proteomic analysis are widely used for typing diagnosis of amyloidosis, the diagnostic utility of immunohistochemical evaluation is not well understood.

Methods: We used immunohistochemical techniques to characterize staining patterns of in-house rabbit polyclonal anti-κ, anti-λ, anti-transthyretin antibodies, and commercial anti-amyloid A and anti-β₂-microglobulin antibodies in 40 autopsy cases.

Results: In thirty cases (75%), the subtype was determined by using the criterion that amyloid is strongly and diffusely positive for one antibody while negative for other antibodies. We then performed proteomic analysis of all 40 cases. In 39 cases, we identified only one amyloid protein and confirmed the immunohistochemically determined subtypes of the abovementioned 30 cases. In seven other cases, we could retrospectively determine subtypes with immunohistochemistry by using information from proteomic analysis, which increased the immunohistochemistry diagnosis rate to 92.5% (37/40). In one case, we identified double subtypes, both immunohistochemically and with proteomic analysis. In the remaining three cases, proteomic analysis was essential for typing diagnosis.

Conclusions: The present findings suggest that combined immunohistochemistry and proteomic analysis is more useful than immunohistochemistry alone. Our findings highlight the importance of carefully interpreting immunohistochemistry for anti-TTR and light chain and offer insights that can guide amyloid typing through immunohistochemistry.

Estrogen receptor α (ERα) regulates several physiological functions. In pathophysiological conditions, ERα is involved in the development and progression of estrogen-sensitive tumors. The ERα gene contains multiple 5'-untranslated exons and eight conventional coding exons and presents multiple isoforms generated by alternative promoter usage and alternative splicing. This gene also possesses non-conventional exons in the 3'- and intronic regions, and alternative use of cryptic exons contributes to further diversity of ERα mRNAs and proteins. Recently, the genomic organization of ERα genes and the splicing profiles of their transcripts were comparatively analyzed in humans, mice, and rats, and multiple ERα isoforms with distinct structures and functions were identified. These transcripts contain cryptic sequences that encode insertion-containing or truncated ERα proteins. In particular, alternative cryptic exons with in-frame stop codons yield transcripts encoding C-terminally-truncated ERα proteins. The C-terminally-truncated ERα isoforms lack part or all of the ligand-binding domain but possess an isoform-specific sequence. Some of these isoforms exhibit constitutive transactivation and resistance to estrogen receptor antagonists. Although numerous studies have reported conflicting results regarding their functions, the critical determinant for their gain-of-function has been identified structurally. Here we review recent progress in ERα variant research concerning the genomic organization of ERα genes, splicing profiles of ERα transcripts, and transactivation properties of ERα isoforms.

Background: No compatibility tests are available for remdesivir other than 0.9% sodium chloride. In this study, we aimed to evaluate the physical compatibility of remdesivir with drugs used in palliative care and COVID-19 treatment.

Methods: Remdesivir was tested for compatibility with 10 different drugs (fentanyl, morphine, hydromorphone, oxycodone, heparin, furosemide, octreotide, acetated Ringer's injection, 2-in-1 peripheral parenteral nutrition, and 2-in-1 total parenteral nutrition). Remdesivir was formulated to a final concentration of 1 mg/mL, and the other drugs were prepared at clinical concentrations. Three test solutions were used for compatibility testing, with remdesivir and the target drugs compounded in a 1:1 ratio. Appearance measurements, including Tyndall effect, turbidity, and pH, were performed immediately after mixing and at 1 h and 4 h after mixing. Changes in appearance, including the Tyndall effect, turbidity (turbidity change of ≥ 0.5 nephelometric turbidity unit [NTU] based on control solution for each test drug), and pH (a change of ≥ 10% based on the pH immediately after mixing) were used to determine physical compatibility.

Results: All the drugs tested were compatible with remdesivir. The combination of remdesivir and furosemide produced the highest turbidity (0.23 ± 0.03 NTU) 1 h after mixing. The lowest and highest pH values were observed at 4 h after mixing for the combinations of remdesivir and morphine (3.23 ± 0.02) and remdesivir and furosemide (8.81 ± 0.06).

Conclusions: The drugs tested in this study show Y-site physical compatibility with remdesivir.

Although necessary for hemodialysis (HD), arteriovenous grafts (AVG) frequently cause complications. Stenosis resulting in venous hypertension is a concern for physicians. Herein, we describe how venous hypertension was improved by using a Viabahn stent graft in an elderly HD patient. An 86-year-old woman started maintenance HD with a left-arm AVG. Two years later, she was referred to our hospital for treatment of juxta-graft-venous junction (GVJ) stenosis. Because of recurrence of stenosis at the juxta-GVJ, she underwent four percutaneous transluminal angioplasty (PTA) procedures during a period of 9 months. One month after the most recent PTA, the patient had redness, swelling, and pain in her left forearm. Venous hypertension was diagnosed on the basis of angiography findings showing regurgitation to the periphery of the basilic vein and juxta-GVJ stenosis. The stenosed juxta-GVJ was adequately expanded with a 7-mm balloon, and a 7-mm stent graft was inserted into the stenosis site. After successful treatment, there was no regurgitation to the periphery of the basilic vein and no symptoms. This complication should be considered when an AVG is created, because cutting off peripheral veins might prevent venous hypertension. Clinicians should perform regular postoperative monitoring.