Journal of Nippon Medical School最新文献

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: 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: 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: 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.

This review examines associations of nutrients and dietary preferences with recurrent pregnancy loss (RPL), miscarriage, and infertility. Research articles, reviews, and meta-analyses of RPL and infertility that focused on nutrition, meals, and lifestyle were reviewed, and associations of nutrients and dietary preferences with pregnancy are discussed in relation to recent research findings. Studies related to RPL were given the highest priority, followed by those dealing with miscarriage and infertility. Multivitamin supplements-even when lacking folic acid or vitamin A-reduced total fetal loss. High-dose folic acid supplementation before conception reduced the risk of miscarriage and stillbirth. A meta-analysis revealed a strong association of vitamin D deficiency/insufficiency with miscarriage. Another meta-analysis revealed that seafood and dairy products reduced the risk of miscarriage, whereas a caffeine intake of 300 mg/day or more was associated with miscarriage. A balanced diet that included nutrients with antioxidant properties helped prevent miscarriage, whereas a diet that included processed foods and nutrients with proinflammatory effects increased the risk of miscarriage. Associations of nutrients with RPL warrant further research.

We report a rare case of choledochal cyst with acute cholangitis that was diagnosed at 37 weeks' gestation and treated by laparoscopic choledochal resection and biliary reconstruction after delivery. A 31-year-old Japanese primigravida at 37 weeks' gestation presented with right upper quadrant pain. The patient was diagnosed as having acute cholangitis due to a type-Ia choledochal cyst, according to the Todani classification, with pancreaticobiliary maljunction. Acute cholangitis improved with conservative treatment, the fetus was delivered by Cesarean section at 38 weeks' gestation, and the patient was treated by laparoscopic choledochal cyst excision and biliary reconstruction at 47 days postpartum. Total operation time was 579 minutes and intraoperative body fluid loss was 100 mL. The patient is now healthy with normal liver function 7 years after the operation. To ensure good outcomes for the mother and fetus, treatment decisions for choledochal cyst diagnosed during pregnancy must be carefully considered.

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.

Symptoms of catatonia include silence, motionlessness, and postural retention. Although it is important to detect and treat catatonia early, before it becomes severe, postoperative cases have inherent risks that hinder diagnosis and treatment. A 60-year-old man with schizophrenia underwent endoscopic/thoracoscopic esophagectomy and was extubated in the operating room. In the intensive care unit (ICU), he had stiffness in the neck, ankles, and knees, catalepsy during passive knee flexion, mild disturbance of consciousness, mild creatine kinase elevation, and respiratory depression. Intravenous diazepam was administered for diagnosis, and the patient's rapid improvement indicated catatonia. He was intubated and started on lorazepam; tapering produced no recurrence of symptoms. The patient was extubated and transferred to the general ward on postoperative Day 2. Because this patient was extubated in the operating room and was managed postoperatively in the ICU with a full-time doctor, his symptoms were easily recognized and early diagnosis was possible. Thus, we were able to administer drug therapy quickly and adequately and perform forward management that accounted for postoperative risks, thereby achieving a favorable outcome.

Background: Foreign body airway obstruction (FBAO) is a life-threatening emergency. Abdominal thrusts are recommended as first aid, but the success rate for this technique is unclear. Using information from a large database of emergency medical services (EMS) data in the United States, we evaluated the success rate of abdominal thrusts and identified patient characteristics that were associated with the success of the technique.

Methods: A retrospective observational study was conducted using data from the National Emergency Medical Services Information System (NEMSIS) to ascertain the success of abdominal thrusts in patients with FBAO from nearly 14,000 EMS agencies. Success was defined by positive evaluations on subjective and objective EMS criteria.

Results: Analysis of 1,947 cases yielded a 46.6% success rate for abdominal thrusts in removing obstructions. The age distribution was bimodal, with peaks during infancy and old age. June had the highest incidence of FBAO. Incidents were most frequent during lunch and dinner times, and most cases occurred in private residences. The first-time success rate was 41.5%, and a lower level of impaired consciousness was associated with lower success rates. A lower incidence of cardiac arrest was noted in successful cases. The success rate was high (60.2%) for children (age ≤15 years), with differences in demographic characteristics and a lower rate of impaired consciousness and cardiac arrests, as compared with unsuccessful interventions in the same age group.

Conclusions: Our study showed a 46.6% success rate for abdominal thrusts in patients with FBAO. The success group had a lower proportion of impaired consciousness and cardiopulmonary arrest than the failure group. Future studies should attempt to identify the most effective maneuvers for clearing airway obstruction.

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.