Journal of Nippon Medical School最新文献

Background: Tarsal tunnel syndrome (TTS) is a common entrapment neuropathy of the posterior tibial nerve. Surgery can be performed less invasively under local anesthesia. We adopted zig-zag skin incision to prevent postoperative wound complications.

Methods: Between July 2022 and June 2023, we operated on 19 legs of 14 consecutive TTS patients (5 males, 11 females; average age 73.3 years). We made a 2- to 3-cm zig-zag skin incision on the tarsal tunnel. After posterior tibial nerve decompression by posterior tibial artery (PTA) transposition, the subcutaneous layer was tightly sutured with 4-0 PDS and the skin was closed with Dermabond Advanced. We investigated adverse events that developed during the first 30 postoperative days and recorded surgical outcomes at the final visit.

Results: In all patients the nerves were successfully decompressed with PTA transposition. There were no intraoperative complications. During the 30 postoperative days there were no adverse events, including wound complications, and patients' symptoms improved significantly.

Conclusion: Zig-zag skin incision was easy and convenient for surgical TTS treatment and may be useful for preventing postoperative wound complications.

Background: Antithrombotic therapy (AT) should generally be avoided within 24 hours after recombinant tissue-plasminogen activator (rt-PA) treatment but should be considered in patients with large-artery atherosclerosis (LAA) who undergo concomitant emergent endovascular treatment (EVT). The aim of the present study was to assess the safety of AT within 24 hours after rt-PA treatment in patients with hyperacute ischemic stroke due to LAA who received concomitant EVT.

Methods: From January 2013 through July 2019, consecutive patients with acute ischemic cerebrovascular disease due to LAA who were admitted within 6 hours from symptom onset were recruited. The patients were classified into six groups based on the reperfusion treatment and early (within 24 hours) AT from rt-PA treatment. Safety outcomes were compared among the groups.

Results: A total of 155 patients (35 women [23%], median age 74 [IQR 66-79] years; NIHSS score 3 [1-10]) were included in the present study. Of these, 73 (47%) received no reperfusion therapy, 24 (15%) received rt-PA treatment and early AT, seven (6%) received rt-PA without early AT, 26 (17%) received EVT only, six (4%) received both rt-PA and EVT without early AT, and 19 (12%) received rt-PA and EVT with early AT. AT was administered a median of 3.9 (1.6-8.0) hours after rt-PA in patients with rt-PA+EVT with early AT. AT within 24 hours after rt-PA and EVT treatment did not increase hemorrhagic complications (p > 0.05 for all).

Conclusion: In this retrospective analyses, early AT administration for patients with hyperacute stroke due to LAA treated with rt-PA plus EVT did not increase hemorrhagic events.

Background: The decreasing trend in the number of young suicides in Japan changed to a flat/increasing trend in 2017. To identify how this change was reflected in young suicide attempters, we investigated changes in the characteristics of young suicide attempters admitted to our emergency room.

Methods: The subjects were suicide attempters younger than 30 years admitted to the Critical Care Medical Center of Nippon Medical School Hospital between January 1, 2010, and December 31, 2021. The means of suicide attempt, sociodemographic data, psychiatric diagnoses, and causes and motives of suicide attempts were retrospectively examined from medical records. We compared post-2017 to pre-2017 suicide attempts and performed a statistical analysis.

Results: The proportion of suicide attempters younger than 30 years was 27.9% (143 of 513) before 2017 and 38.0% (132 of 347) after 2017, a significant increase. From 2017 to 2021, there was a significant increase in the number of female suicide attempters younger than 30 years and in the percentage of drug overdoses.

Conclusions: The proportion of suicide attempters younger than 30 years was significantly higher after the start of 2017 than before 2017, possibly because of an increase in drug overdoses.

Stridor is caused by oscillation of the narrowed upper airway. The most common cause of neonatal stridor is laryngomalacia, followed by vocal fold abduction dysfunction. Herein, we present two neonatal cases of idiopathic dysfunction of vocal fold abduction. A neonate was admitted to the neonatal intensive care unit (NICU) on day 4 of life for inspiratory stridor, intermittent subcostal retraction, and cyanosis. A second neonate was admitted to the NICU on day 7 of life for inspiratory stridor and cyanosis when crying. Neither patient had dysmorphic features or unusual cardiac ultrasonography findings. The diagnosis was confirmed by laryngo-bronchoscopy. Conservative treatment with biphasic positive airway pressure was effective in both cases and symptoms resolved within a few months. Resolution of vocal fold abduction dysfunction was confirmed by repeat endoscopy. Clinical manifestations of vocal fold abduction dysfunction vary widely. Although most cases resolve spontaneously, prolonged tube feeding, or even tracheostomy, is needed in some severe cases. Diagnosis of vocal fold abduction dysfunction requires a laryngo-bronchoscopy study; thus, there may be a large number of undiagnosed patients. Vocal fold abduction dysfunction should be considered in the differential diagnosis for neonatal inspiratory stridor.

Background: The incidence of alcoholic liver cirrhosis (ALC) is increasing. However, few reports have focused on ALC-derived esophageal varices (EV). We retrospectively examined differences in overall survival (OS) and EV recurrence rate in patients after endoscopic injection sclerotherapy (EIS) for ALC and hepatic B/C virus liver cirrhosis (B/C-LC).

Methods: We analyzed data from 215 patients (B/C-LC, 147; ALC, 68) who underwent EIS. The primary endpoints were OS and EV recurrence in patients with unsuccessful abstinence ALC and those with uncontrolled B/C-LC, before and after propensity score matching (PSM) to unify the patients' background. The secondary endpoints were predictors associated with these factors, as determined by multivariate analysis.

Results: The observation period was 1,430 ± 1,363 days. In the analysis of all patients, OS was significantly higher in the ALC group than in the B/C-LC group (p = 0.039); however, there was no difference in EV recurrence rate (p = 0.502). Ascites and history of hepatocellular carcinoma (HCC) (p = 0.019 and p < 0.001, respectively) predicted OS, whereas age and EV size predicted recurrence (p = 0.011 and 0.024, respectively). In total, 96 patients without an HCC history were matched by PSM, and there was no significant difference in OS or EV recurrence rate (p = 0.508 and 0.246, respectively).

Conclusion: When limited to patients without a history of HCC, OS and the EV recurrence rate were comparable in patients with ALC who continued to consume alcohol and those with B/C-LC without viral control.

Background: The standard treatment for Kawasaki disease is immunoglobulin therapy, but the high frequency of coronary sequelae in immunoglobulin-refractory cases indicates a need for further improvement in treatment.

Methods: Kawasaki disease-like vasculitis was induced in 5-week-old DBA/2 mice by intraperitoneal administration of 0.5 mg Candida albicans water-soluble fraction (CAWS) daily for 5 days followed by daily administration of candesartan, an angiotensin receptor blocker. The vasculitis suppression effect was confirmed histologically and serologically in mice sacrificed at 28 days after the start of candesartan.

Results: The area of inflammatory cell infiltration at the aortic root was 2.4±1.4% in the Control group, 18.1±1.9% in the CAWS group, and 7.1±2.3%, 5.8±1.4%, 7.6±2.4%, and 7.9±5.0% in the CAWS+candesartan 0.125-mg/kg, 0.25-mg/kg, 0.5-mg/kg, and 1.0-mg/kg groups, respectively (p=0.0200, p=0.0122, p=0.0122, and p=0.0200 vs. CAWS, respectively). The low-dose candesartan group also showed significantly reduced inflammatory cell infiltration. A similar trend was confirmed by immunostaining of macrophages and TGFβ receptors. Measurement of the inflammatory cytokines IL-1β, IL-6, and TNF-α confirmed the anti-vasculitis effect of candesartan.

Conclusions: Candesartan inhibited vasculitis even at clinical doses used in children, making it a strong future candidate as an additional treatment for immunoglobulin-refractory Kawasaki disease.

Background: Tarsal tunnel syndrome (TTS) is a common entrapment neuropathy that is sometimes elicited by ganglia in the tarsal tunnel.

Methods: Between August 2020 and July 2022, we operated on 117 sides with TTS. This retrospective study examined data from 8 consecutive patients (8 sides: 5 men, 3 women; average age 67.8 years) with an extraneural ganglion in the tarsal tunnel. We investigated the clinical characteristics and surgical outcomes for these patients.

Results: The mass was palpable through the skin in 1 patient, detected intraoperatively in 1 patient, and visualized on MRI scanning in the other 6 patients. Symptoms involved the medial plantar nerve area (n = 5), lateral plantar nerve area (n = 1), and medial and lateral plantar nerve areas (n = 2). The interval between symptom onset and surgery ranged from 4 to 168 months. Adhesion between large (≥20 mm) ganglia and surrounding tissue and nerves was observed intraoperatively in 4 patients. Of the 8 patients, 7 underwent total ganglion resection. There were no surgery-related complications. On their last postoperative visit, 3 patients with a duration of symptoms not exceeding 10 months reported favorable outcomes.

Conclusions: Because ganglia eliciting TTS are often undetectable by skin palpation, imaging studies may be necessary. Early surgical intervention appears to yield favorable outcomes.

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.

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.