Journal of Nippon Medical School最新文献

Background: No accurate prognostic tool is available for patients with cancer who spend their final days at home. In this study, we examined whether performance status (PS) and the palliative prognostic index (PPI), a well-known prognostic tool in palliative care units, could be used to predict prognosis in the home care setting at the time of intervention by home physicians.

Subjects and methods: Using medical records, we conducted a retrospective analysis of 132 patients who were referred to the Home Clinic Naginoki for home care for terminal stages of carcinoma in situ. Based on the status at the time of the first visit, the PPI-Low group was defined as those scoring six or below and the PPI-High group as those scoring greater than six.

Results: The PPI-high group had a significantly poorer prognosis within 21 days than the PPI-low group (21-day-OS; Low 71.4% vs. High 13.2%; p<0.001). The Eastern Cooperative Oncology Group (ECOG) PS alone predicted better prognosis in the group with PS of one or two (21-day survival 90.1%), and the PPI score further significantly stratified the prognosis for patients with PS three or four, with a trend toward poor prognosis (p ≤ 0.005).

Conclusion: ECOG PS 1 or 2 has a favorable prognosis and that using PPI in ECOG PS 3 or 4 leads to a more accurate prognosis prediction. PPI evaluated during the hospital-based treatment of patients with terminal cancer can also be used to predict prognosis if the patient is transitioned to a home care environment.

Background: Although several clinical guidelines recommend vasodilator therapy for non-occlusive mesenteric ischemia (NOMI) and immediate surgery when bowel necrosis is suspected, these recommendations are based on limited evidence.

Methods: In this retrospective nationwide observational study, we used information from the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018 to identify patients with NOMI who underwent abdominal surgeries on the day of admission. We compared patients who received postoperative vasodilator therapy (vasodilator group) with those who did not (control group). Vasodilator therapy was defined as venous and/or arterial administration of papaverine and/or prostaglandin E1 within 2 days of admission. The primary outcome was in-hospital mortality. Secondary outcomes included the prevalence of additional abdominal surgery performed ≥3 days after admission and short bowel syndrome.

Results: We identified 928 eligible patients (149 in the vasodilator group and 779 in the control group). One-to-four propensity score matching yielded 149 and 596 patients for the vasodilator and control groups, respectively. There was no significant difference in in-hospital mortality between the groups (control vs. vasodilator, 27.5% vs. 30.9%; risk difference, 3.4%; 95% confidence interval, -4.9 to 11.6; p=0.42) and no significant difference in the prevalences of abdominal surgery, bowel resection ≥3 days after admission, and short bowel syndrome.

Conclusions: Postoperative vasodilator use was not significantly associated with a reduction in in-hospital mortality or additional abdominal surgery performed ≥3 days after admission in surgically treated NOMI patients.

Background: Although occlusion of the right coronary artery (RCA) is common in the remote stages of Kawasaki disease, revascularization of the RCA is challenging in children and is usually managed by observation without intervention.

Methods: Using adenosine-stress ¹³N-ammonia myocardial perfusion positron emission tomography, we evaluated coronary circulation in 14 patients (12 males) with RCA occlusion to identify ischemia (myocardial flow ratio < 2.0) in the RCA region and examined hemodynamics, cardiac function, and coronary aneurysm diameter. These variables were also compared in patients with/without RCA segmental stenosis (SS).

Results: There were five cases of ischemia in the RCA region. RCA myocardial blood flow (MBF) at rest was higher in patients with ischemia than in those without ischemia, but the difference was not significant (1.27 ± 0.21 vs. 0.82 ± 0.16 mL/min/g, p = 0.2053). Nine patients presented with RCA SS, and age at onset of Kawasaki disease tended to be lower in those with SS. The maximum aneurysm diameter of RCA was significantly smaller in patients with SS (10.0 ± 2.8 vs. 14.7 ± 1.6, p = 0.0239). No significant differences in other variables were observed between patients with/without ischemia and SS.

Conclusions: At rest, MBF in the RCA region was relatively well preserved, even in patients with RCA occlusion, and there was no progressive deterioration in cardiac function. Adenosine stress showed microcirculatory disturbances in only half of the patients, indicating that it is reversible in children with Kawasaki disease.

Background: Basal cell carcinoma (BCC) is the most common cutaneous malignancy. BCCs occur mainly in exposed areas, such as the face and scalp. Therefore, surgical resection with narrow margins is highly desirable. However, narrow margins may increase the risk of positive histopathological margins. Outcomes for such treatment might be unfavorable, but evidence for such a conclusion is lacking.

Methods: Between April 2015 and November 2023, a total of 230 Japanese cases with BCC which underwent surgical resection with 2-mm, 3-mm, or 5-mm margins were followed in our hospital. We conducted a retrospective review that focused on the recurrence rate and histopathological margins.

Results: Recurrence was recorded if the follow-up time was longer than 3 months. One of the 198 cases (0.5%) developed a recurrence. The mean lateral and deep histopathological margins were 2,525.4 μm (30.8-14,034.6 μm) and 3,409 μm (199.9-16,523.6 μm), respectively. Recurrence rate was associated with tumor size and clinical tumor border. However, histopathological margin was not associated with recurrence rate, even when it was less than 1,000 μm.

Conclusions: A narrow histopathological margin is acceptable for surgical resection of BCC in Japanese patients.

Background: First reported by Malherbe in 1880, pilomatricoma is a common benign skin tumor generally believed to occur mainly in children and adolescents. We conducted this study to better define the characteristics of pilomatricoma and compare our findings with current knowledge.

Methods: Patients diagnosed pathologically with pilomatricoma from 2016 through 2020 at Nippon Medical School Musashi Kosugi Hospital were included (1,559 patients, 1,590 tumors). Clinicopathological characteristics were analyzed.

Results: The male to female ratio was 1:1.6, and the most common tumor site was the upper limbs (33.7%). Preoperative diagnosis was correct in 48.5% of the patients, and their average age at resection was 33.5 years. Resection was carried out in 70% of the patients within 1 year, but time to resection was more than 1 year in the other 30%. Pathologically, squamous stratifying keratinocytes were observed in 41.7% of the patients, cells with a large pale pink cytoplasm in 38.9%, hair papilla-like structures in 33.9%, ossification in 15.7%, trichohyalin granules in 11.9%, and aggregations of follicular germinative cells in 7.8%. Of the chronological and morphological stages proposed by Kaddu (stage 1: early, stage 2: fully developed, stage 3: early regressive, stage 4: late regressive), stage 3 was the most common (70.6%).

Conclusion: Pilomatricoma is more common in females, regardless of ethnicity or age, but the tumor location in the upper limbs commonly observed in Japanese patients may indicate ethnic differences. Pathologically, the fact that cells linked to follicular differentiation are observed suggests that pilomatricoma is a complex panfollicular neoplasm. Time to resection appears to correlate with Kaddu stages. Factors such as age, location, sex, depth, and stage may affect the pathological features of this tumor.

Background: Vascular access intervention therapy (VAIVT) is widely used as a treatment for arteriovenous fistula (AVF) failure. However, recurrent AVF failure is a major concern for dialysis patients. By prospectively observing patients after an initial VAIVT, we attempted to identify risk factors for developing restenosis of AVF.

Methods: This single-center prospective study evaluated 57 patients who underwent their first VAIVT procedure at our hospital from April 2022 through March 2023. We performed blood and biochemical tests during the first VAIVT to collect data on clinical variables. Ultrasonography was used to measure vessel diameter reduction rate, flow volume (FV) reduction rate, and increase in resistance index (RI) rate over a 3-month period.

Results: Within 3 months, 24 patients developed short-term shunt stenosis and 30 did not. Three were not traceable. In a comparison of the two groups, significant differences were observed in albumin (ALB), FV, RI, and elbow shunt. Analysis of change rates in the three ultrasound findings identified five factors (hematocrit, platelet count, activated partial thromboplastin time, ALB, and FV). The results of logistic regression models revealed that ALB was the most significant predictive factor for short-term shunt stenosis (p = 0.031).

Conclusion: In conclusion, our findings suggest that low serum ALB at the time of initial VAIVT is a significant risk factor for short-term recurrence of AVF failure in hemodialysis patients. These findings emphasize the importance of careful routine monitoring to reduce the risk of AVF failure and associated complications.

Background: Alcoholic steatohepatitis and nonalcoholic steatohepatitis-related liver cirrhosis (ASH/NASH-LC) are major causes of esophageal varices (EVs). However, the association between high visceral fat and exacerbation of EVs remains unclear. The aim of this study was to clarify the association of visceral fat and recurrence rate of EVs in ASH/NASH-LC and to identify independent predictors associated with recurrence.

Methods: We retrospectively evaluated data from 94 patients who underwent endoscopic injection sclerotherapy for EVs with ASH/NASH-LC. Using the receiver operating characteristic curve for the cut-off value of visceral fat index (VFI; 46.4 cm²/m²), we classified patients as having a high VFI (n = 53) or low VFI (n = 41). Propensity score matching was used to align for background factors, and the recurrence rate of EVs was compared between the two groups. Predictors associated with esophageal variceal recurrence were identified by multivariate analysis. The recurrence rate in patients with viral LC was also investigated.

Results: In the overall analysis, the recurrence rate was significantly higher in the high VFI group than in the low VFI group (P = 0.023). The recurrence rate was also higher in the high VFI group than in the low VFI group after propensity score matching, in which 19 patients were matched in each group (P = 0.048). VFI and Child-Pugh score were independently associated with recurrence. Recurrence rates were comparable between the two groups in viral LC patients.

Conclusions: Worsening of variceal recurrence was observed in high visceral fat patients in ASH/NASH-LC but not in viral LC. Furthermore, high visceral fat was an independent predictor associated with variceal recurrence.

Background: Rehabilitation therapists are sometimes unaware of the possibility of undiagnosed atrial fibrillation (AF) and the importance of AF detection. Thus, we aimed to increase awareness among rehabilitation therapists of the importance of AF detection at rehabilitation hospitals during regular pulse checks of patients with ischemic stroke.

Methods: In this multicenter prospective observational study, we enrolled patients with noncardiac stroke. The therapists performed pulse checks before, during, and after rehabilitation during the inpatient period. Electrocardiography (ECG) was performed to check for AF when arrhythmia or tachycardia was detected. The characteristics, ECG data, laboratory data, complications such as stroke recurrence, and functional outcomes of the patients were investigated.

Results: Among 158 included patients (97 [61.4%] men, median age 77 [interquartile range {IQR}, 71-84] years), the median stay in stroke centers was 21 (IQR,15-31) days. Regarding medication administered upon admission, 94 (59.5%) patients received single antiplatelet therapy and 14 (8.9%) patients received no antithrombotic medication. Electrocardiography and blood testing were performed on admission in 112 (70.9%) and 136 (87.3%) patients, respectively. The median hospitalization period in the rehabilitation center was 179 (IQR, 90-272) days. Four patients (2.5%) experienced recurrent events. No patients developed AF or palpitations.

Conclusions: Although our results suggest increased awareness of AF detection in rehabilitation centers, AF was not detected. AF detection using pulse checks alone may be challenging; thus, further investigation is warranted.

Background: The primary mechanism of diurnal gastroesophageal reflux (GER) is transient lower esophageal sphincter relaxation (TLESR) in both healthy persons and patients with gastroesophageal reflux disease (GERD). However, few studies have examined nocturnal GER. Using portable high-resolution manometry (HRM), esophageal pH, and electroencephalography (EEG), we investigated the association of onset of nocturnal GER with sleep depth in healthy Japanese adults.

Methods: We recruited ten healthy men (mean age 33.5 ± 4.2 years) with no reflux symptoms, no history of surgery, and no current medication use. HRM and an esophageal pH catheter were inserted in the evening. The participants returned home after consuming a test meal, and EEG was placed at home before bedtime to measure sleep depth.

Results: The main mechanism underlying nocturnal GER was TLESR (15/17 episodes: 88.2%). The rate of TLESR with nocturnal GER during sleep was high (51.9%, 27/52 episodes). Sleep depth during TLESR was 44.2% (23/52 times) awake and 34.6% (18/52 times) shallow sleep (N1-2). Sleep depth during TLESR with nocturnal GER was 74.0% (20/27 time) awake and 18.5% (5/27 times) shallow sleep (N1-2).

Conclusion: The primary mechanism underlying nocturnal GER was TLESR in healthy Japanese men. TLESR and TLESR with nocturnal GER were more frequent during awakenings and shallow sleep.

Background: Anatomical landmarks and range-of-motion (ROM) techniques are commonly used to rotationally align the tibial component in total knee arthroplasty (TKA). This study investigated; 1) the difference in tibial rotational alignment between the ROM technique and Akagi's line, 2) the influence of preoperative deformity and intraoperative gaps on this difference, and 3) intraoperative tibial rotational kinematics associated with these 2 techniques.

Methods: Patients who underwent cruciate-substituting (CS) TKA (Evolution, Microport Orthopedics) for knee osteoarthritis were enrolled. Intraoperatively, the rotational alignment of the tibial component was determined with the ROM technique and recorded. The difference from the value determined using Akagi's line was evaluated. Correlations among preoperative coronal deformity, postoperative coronal alignment, and intraoperative gaps between the femur and tibia were evaluated. Differences in knee kinematics (rotational movement of the tibia against the femur) between the 2 techniques were compared.

Results: This study included 34 knees from 34 patients. The rotational alignment of the tibial component using the ROM technique was 2.5±6.4° externally rotated in relation to that determined using Akagi's line (p=0.029), which was increased in knees with a smaller preoperative medial proximal tibial angle (r=0.45). Tibial rotational kinematics did not significantly differ between the 2 techniques.

Conclusions: The ROM technique and Akagi's line yielded significantly different values for the rotational alignment of the tibial component. Orthopedic surgeons using Evolution (CS) should be reminded that in knees with proximal tibial varus deformity, the ROM technique will result in external rotation of the tibial component in relation to Akagi's line.