The comparison of the clinical outcomes and costs between surgical aortic valve replacement and transcatheter aortic valve implantation based on the Japanese Diagnosis Procedure Combination database

PURPOSE

We evaluated the clinical outcomes and costs of surgical aortic valve replacement (SAVR) and transfemoral transcatheter aortic valve implantation (TAVI) for aortic stenosis using the Japanese Diagnosis Procedure Combination (DPC) database.

METHODS

Using our extraction protocol, we retrospectively analyzed summary tables in the DPC database from 2016 to 2019, which were provided by the Ministry of Health, Labor and Welfare. A total of 27,278 patients were available (SAVR, n = 12,534; TAVI, n = 14,744).

RESULTS

The TAVI group was older than the SAVR group (SAVR vs. TAVI: 74.6 vs. 84.5 years; P < 0.01), with a lower in-hospital mortality (1.0 vs. 0.6%; P < 0.01) and a shorter hospital stay (26.9 vs. 20.3 days; P < 0.01). TAVI conferred more total medical service reimbursement points than SAVR (493,944 vs. 605,241 points; P < 0.01), especially materials points (147,830 vs. 434,609 points; P < 0.01). Total insurance claims for TAVI were approximately 1 million yen higher than those for SAVR. Regarding the details of costs, only the operation cost was higher, while other costs were lower with TAVI than with SAVR.

CONCLUSION

Our analysis revealed that both SAVR and TAVI showed acceptable clinical outcomes. TAVI was associated with higher total insurance claims than SAVR. If the material cost of TAVI operations can be reduced, greater cost-effectiveness can be expected.

Calcium Polystyrene Sulfonate Crystal-related Airway Obstruction

An 83-year-old man diagnosed with multiple myeloma presented with renal failure and hyperkalemia. The patient was treated with calcium polystyrene sulfonate (CPS; kalimate) for hyperkalemia. On the 10th day after starting CPS, airway obstruction due to the presence of a mass was observed, and the patient died on that same day. Autopsy revealed that the mass was located between the trachea and epiglottis and it was determined to consist of CPS-related mosaic crystals. There was a protrusion within the trachea surrounding the CPS crystals, inflammatory cells, and granulation tissue. This case suggests that CPS is associated with not only gastrointestinal complications, but also with airway complications.

Long-Term Results of a Multi-Institutional Study of Dynamic Tumor Tracking-Stereotactic Body Radiotherapy for Lung Tumors

PURPOSE/OBJECTIVE(S)

We had conducted a multi-institutional phase II study to evaluate the safety and efficacy of dynamic tumor tracking-stereotactic body radiotherapy (DTT-SBRT) for lung tumors. The primary endpoint was 2-year local control, which was reported to be 95.2%. After the initial evaluation of the primary endpoint, the study was extended as an observational study which was designed to evaluate 5-year survival and late toxicities. We present the long-term results of DTT-SBRT for lung tumors.

MATERIALS/METHODS

The main eligibility criteria for the study were as follows: (1) primary or metastatic lung cancer with a diameter of 5 cm or less, and up to 3 lesions without any extrapulmonary lesions; (2) ineligibility to standard surgery, or patient's refusal of surgery; (3) ECOG-PS of 0 to 2; and (4) expected range of respiratory motion of 10 mm or more. The study included 48 patients from four institutions with the median age of 80 years (range, 49-90 years). Forty-two patients had primary non-small-cell lung cancer, and 6 patients had metastatic lung tumors. Forty-eight tumors (median diameter, 23.5 mm; range, 5-47 mm) in 48 patients were targeted for DTT-SBRT using a gimbal-mounted linear accelerator. Prior to treatment planning, spherical gold markers were placed around the tumor to detect internal tumor motion using fluoroscopy. The prescribed dose was 50 Gy in four fractions. Treatment beams were delivered with DTT according to a 4D model that predicts internal tumor motion with abdominal wall motion. DTT-SBRT was successfully delivered to all but one patient who had poor correlation between abdominal wall and tumor motion.

RESULTS

Median follow-up period at data cutoff was 5.0 years (interquartile range, 3.1-6.3 years). Twenty-nine patients died; the causes of death were cancer-specific in 10 patients, comorbidity in 14 patients (pulmonary disease, renal failure, cerebral infarction, other malignancies, etc.), and unknown in 5 patients without cancer recurrence. Overall survival at 5 years was 51.5% (95% confidence interval [CI], 36.5-64.6%). Progression-free survival and local control at 5 years were 41.0% (95% CI, 27.0-54.5%) and 92.6% (95% CI, 78.7-97.6%), respectively. There were no grade 4-5 toxicities. One patient (2%) developed grade 3 radiation pneumonitis at 3 months. Grade 2 toxicities were observed in 9 patients (19%), including dyspnea, radiation pneumonitis, pleural effusion, rib fracture, and dermatitis.

CONCLUSION

Dynamic tumor tracking SBRT achieved the long-term efficacy with low incidence of severe toxicities in lung tumors with respiratory motion. In this elderly patient cohort, non-cancer deaths were observed more than cancer-specific deaths.

A sealant with a hemostatic mechanism independent of the blood coagulation function was effective in both elective and emergency surgery for thoracic aorta

OBJECTIVES

Matsudaito is a unique surgical sealant with a powerful hemostatic effect that works independent of a patient's blood coagulation function. Because of its mechanism, this sealant is expected to be particularly useful in patients with a poor blood coagulation function, such as in cases of acute aortic syndrome requiring emergency surgery. We, therefore, evaluated the hemostatic static effect of the sealant in both emergency and elective surgery of the thoracic aorta.

METHODS

We used data obtained from post-marketing surveillance of the sealant. Patients who underwent replacement of the thoracic aorta were enrolled. The hemostatic effect was evaluated as effective if a further hemostatic procedure was not performed after applying the sealant.

RESULTS

From 46 hospitals in Japan, a total of 542 patients (327 elective and 215 emergency cases) were enrolled. Hospital mortality was 4.0% and 11.6% in elective and emergency cases, respectively (p < 0.05). Among the 1039 anastomoses (609 elective and 430 emergency cases), effective hemostasis was confirmed in 436 (71.6%) elective and 259 (60.2%) emergency cases. The data from the clinical trial of the sealant showed a hemostatic rate of 44.4% in elective control cases without the sealant.

CONCLUSION

Given that the hemostatic rate in emergency surgery with the sealant seemed to be better than that in elective surgery without the sealant (determined from the clinical trial), we concluded that the sealant was effective in both emergency and elective thoracic surgery of the aorta.

Cytological features of stromal spindle cells and their prognostic significance in lung adenocarcinoma

INTRODUCTION

Cancer-associated fibroblasts (CAFs) in the tumour microenvironment play a key role in tumour development, proliferation, invasion, and metastasis. The cytological features of spindle cells including CAFs-defined as stromal spindle cells (SSCs) adjacent to cancer cells-are frequently encountered in pulmonary adenocarcinomas. This study aimed to investigate the association between the presence of SSCs in cytological specimens and the clinicopathological features.

METHODS

We evaluated 211 patients with pulmonary adenocarcinoma who underwent surgical resection. All participants had cytological specimens corresponding to the histological specimens available for review.

RESULTS

Of the 211 cases examined, 89 were SSC-positive (SSC+ ) and 122 were SSC-negative (SSC- ). SSC+ cases were more frequently associated with higher pathological stage (P < 0.001), lymph node metastasis (P = 0.002), anaplastic lymphoma kinase (ALK) gene rearrangement (P = 0.04), high tumour grade (P < 0.001), solid and micropapillary predominant pattern (P = 0.02), and lymphatic vessel (P = 0.003), blood vessel (P < 0.001), and pleural invasion (P = 0.03) as compared to SSC- cases. Patients with SSC+ adenocarcinoma had a significantly shorter recurrence-free survival than those with SSC- adenocarcinoma (P = 0.009). Cytologically, necrotic background (P = 0.002), mucinous cancer cells (P = 0.02), pleomorphic cells (P < 0.001), and mutual cell inclusions (P = 0.01) were observed more frequently in SSC+ adenocarcinomas.

CONCLUSIONS

The presence of SSCs could be an important cytological feature for predicting poor prognosis in lung adenocarcinomas.

Total Talar Replacement: Surgical Technique

Background

Total talar replacement is a salvage procedure for end-stage osteonecrosis of the talus. A customized total talar implant is designed with use of computed tomography scans of the healthy opposite side and made of alumina ceramic. The use of such an implant is potentially recommended, with a guarded prognosis, for the treatment of traumatic, steroidal, alcoholic, systemic lupus erythematous, hemophilic, and idiopathic pathologies. The talus is surrounded by the tibia, fibula, calcaneus, and navicular bones, which account for a large portion of the articular surface area. Yoshinaga9 reported that alumina ceramic prostheses were superior in terms of congruency and durability of articular cartilage compared with 316L stainless steel in an in vivo test in dogs. Therefore, alumina ceramic is an ideal material for replacement of the talus to preserve postoperative hindfoot mobility.

Description

Total talar replacement is performed with the patient in a supine position. The anterior ankle approach is utilized to exteriorize the talus, facilitating dissection of the ligaments and joint capsule attached to talus. The first osteotomy is performed around the talar neck, perpendicular to the plantar surface of the foot. The talar head fragment is then removed. Subsequent talar osteotomies are performed parallel to the first cutting line, at approximately 2-cm intervals. The attaching articular capsule and ligaments are dissected in each step. The removal of the posterior talar bone fragments is succeeded by careful dissection of the ligament and joint capsule under the periosteum. After dissecting the remaining interosseous talocalcaneal ligament, the foot is distally retracted and a customized talar implant is inserted. After testing and confirming the stability and mobility of the implant, the wound is irrigated with use of normal saline solution. A suction drain is placed anterior to the implant, and the skin is closed after repairing the extensor retinaculum.

Alternatives

In cases with a limited area of necrosis, symptoms may improve with a patellar tendon-bearing brace. However, in many cases of symptomatic osteonecrosis of the talus, nonoperative treatment is not expected to improve symptoms. Alternative surgical procedures include ankle arthrodesis and hindfoot arthrodesis, but there are risks of nonunion, leg-length discrepancy as a result of extensive bone loss, and functional decline because of loss of hindfoot motion.

Rationale

Total talar replacement is a fundamentally unique treatment concept in which the entire talus is replaced with an artificial implant. Compared with ankle or hindfoot arthrodesis, this procedure preserves the range of motion of the foot and allows for earlier functional recovery. Postoperative results were satisfactory in the subjective evaluation, with no failure requiring revision. This procedure reduces the risk of postoperative failure in patients who are elderly and/or have underlying diseases, who often require a long recovery time. As the talus is a small bone with uniquely vulnerable vascularity, treatment of talar pathology is usually difficult; however, total talar replacement is a potential treatment option for patients with end-stage osteonecrosis of the talus without obesity.

Expected Outcomes

The greatest advantage of total talar replacement is the preservation of ankle and hindfoot mobility. Second, a customized talar prosthesis based on a mirrored model of the contralateral, unaffected talus will allow the smooth transfer of body weight from the lower leg to the heel and forefoot-a requirement for a stable gait. Third, the artificial talar prosthesis has a potential advantage in that it minimizes leg-length discrepancy, preventing daily inconvenience for the patient. Twenty years after the development of the implant, replacement with a total talar prosthesis resulted in a median score of 97 out of 100 on the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale as an objective evaluation and yielded a significant improvement in the subjective evaluation of the Ankle Osteoarthritis Scale (AOS) in a follow-up study over 10 years. The median ankle joint range of motion was 45°, and complications requiring implant replacement never occurred.

Important Tips

The skin incision should be placed at the center of the inferior tibial articular surface and curved medially to avoid the medial branch of the superficial peroneal nerve.During the resection of the talus, the attaching ligament and joint capsule are recommended to be debrided prior to osteotomy.Bone fragments should be removed as an entire block in order to avoid leaving small fragments.When inserting the artificial talus, pull the entire foot distally by grasping the heel in order to avoid excessive plantar flexion.During wound closure, the extensor retinaculum should be repaired to avoid skin bowstringing.Although favorable long-term results have been reported, postoperative outcomes in patients with high body mass index have not been adequately investigated. This procedure should be carefully selected on the basis of the physical characteristics of the patient.

Acronyms and Abbreviations

AVN = avascular necrosis (osteonecrosis)SLE = systemic lupus erythematousCAD = computer-aided designCT = computed tomographyJSSF = Japanese Society for Surgery of the FootIQR = interquartile rangeAOS = Ankle Osteoarthritis ScalePWB = partial weight-bearingW = weeks.

The Long-Term Clinical Results of Total Talar Replacement at 10 Years or More After Surgery

BACKGROUND

Total talar replacement has been reported to have favorable short-term and intermediate-term results for the treatment of osteonecrosis of the talus. The purpose of this study was to evaluate the long-term clinical results of total talar replacement for a minimum of 10 years after the surgical procedure.

METHODS

From October 2005 to April 2011, 19 ankles in 18 patients (1 male and 17 female) were treated using a total talar prosthesis for osteonecrosis of the talus. The median follow-up period was 152 months (interquartile range [IQR], 138, 160 months). The Ankle Osteoarthritis Scale (AOS) score, the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale score, and the presence of osteophytes and degenerative changes in the adjacent joints were assessed preoperatively and at the final follow-up. Subsidence of the prosthesis was also assessed at the earliest opportunity for full weight-bearing and the final follow-up. The postoperative range of motion of the ankle was assessed at the final follow-up.

RESULTS

The median scores for all subscales of the AOS significantly improved. The median JSSF Ankle-Hindfoot Scale score significantly improved from 58 (IQR, 55, 59.5) to 97 (IQR, 87, 99.5). In the subcategories of this scale, the median pain score improved from 20 (IQR, 20, 20) to 40 (IQR, 30, 40), and the median function score improved from 28 (IQR, 26, 30.5) to 47 (IQR, 47, 50). The median postoperative range of motion of the ankle was 45° (IQR, 42.5°, 55°). Subsidence of the implant was not recognized at the final follow-up (p = 0.083). Proliferation of osteophytes and degenerative changes in the adjacent joints did not affect the overall results.

CONCLUSIONS

The customized alumina ceramic total talar prosthesis produced stable clinical outcomes over 10 years, and the patients treated with total talar replacement showed favorable clinical results over this time frame.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Sociodemographic and work-related factors influencing long working hours among cardiovascular surgeons in Japan: a cross-sectional study

The maximum limit on overtime working hours for physicians will be applied from 2024. To explore sociodemographic and work-related factors influencing overtime work among cardiovascular surgeons (CS) in Japan. This cross-sectional study included 607 CS who responded to an online survey. Working hours were categorized into ≤60 hours, 60-79 hours, and ≥80 hours per week according to Japan Ministry of Health, Labour and Welfare. Adjusted odds ratios (aOR) were calculated using a multinomial analysis with stepwise reduction after adjustment for potential confounders. Compared to ≤60 hours, significant factors related to 60-79 hours and ≥80 hours per week were age groups of 30s to 50s versus 60s (aOR: 7.48-3.22 and 23.64-4.87), management with cardiovascular drugs (aOR: 1.87 and 5.80), and postoperative wound management (aOR: 0.47 and 0.16), respectively. Significantly related informed consent for surgery (aOR: 3.29) was seen in 60-79 hours. Contrarily, CS who worked for ≥80 hours took on-duty 5 times or more per month (aOR: 3.89), performed night or holiday calls 20 times or more per month (aOR: 2.26), and attended the intensive care unit (aOR: 3.12). These findings suggest that younger, and some non-surgical work-related factors could influence long working hours among CS.

A preliminary study of the safety and effectiveness of isoproterenol loading transesophageal echocardiography in atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with sludge or severe spontaneous echo contrast (SEC) in the left atrial appendage (LAA), isoproterenol loading transesophageal echocardiography (ISP-TEE) has been reported to check the presence of thrombus in the LAA, as the sludge or severe SEC disappears (Figure 1).

Purpose

The aim of this study was to assess the safety of ISP-TEE for the identification of LAA thrombus and the hemodynamic changes in the LAA caused by ISP loading.

Methods

We prospectively enrolled 25 patients with atrial fibrillation (AF) and sludge or SEC in the LAA who underwent ISP-TEE from April 2020 to July 2021. ISP was administered intravenously to achieve the target heart rate (HR) defined as follows: Max HR [beats per minutes: bpm] = 220 – age (years), Target HR [bpm] = Max HR × 0.8. Patients with tachycardia exceeding Max HR before ISP administration, hemodynamic instability, and other contraindications to ISP were excluded from the study. To assess the safety of ISP-TEE, we evaluated patients’ condition, changes in systolic blood pressure (sBP) and HR before and after ISP loading. We also assessed the presence or absence of worsening heart failure, new arrhythmias other than atrial fibrillation, and cerebral infarction or transient ischemic attack during the examination, and after 24 hours. Hemodynamic evaluation was performed using LAA blood flow velocity, LAA tissue Doppler imaging (TDI) velocity, and LAA volume fraction (LAAVF) defined as follows: LAAVF (%) = (Max LAA volume – Min LAA volume) / Max LAA volume × 100. Quantification of LAA volume was performed using the stacked-contour method of a 3-dimensional TEE full-volume acquisition.

Results

Among 25 patients, 13 patients had sludge or grade3 SEC, 7 patients had grade2 SEC, 5 patients had grade1 SEC. HR after ISP loading was significantly higher than before loading, but sBP did not change significantly before and after ISP loading. No complications due to ISP loading were observed during examination and after 24 hours. After ISP loading, there were 18 patients with grade 1 SEC or no SEC (classified as Group1), 7 patients had residual sludge or grade 2 to 3 SEC (classified as Group2). The differences in LAA blood flow velocity between before and after ISP loading was faster in Group1 than in Group2: 13.0 ± 10.5 vs 2.6 ± 4.2. p = 0.019. The differences in TDI velocity was also faster in Group1 than in Group2: 1.46 ± 1.14 vs 0.19 ± 0.50, p = 0.010. The differences in LAAVF was higher in Group1 than in Group2: 13.7 ± 10.3 vs 2.2 ± 2.0, p = 0.009.

Conclusions

In our study, no complications were observed in ISP-TEE for the identification of LAA thrombus. Patients with grade 1 SEC or no SEC, the LAA function was increased by ISP loading. These results may provide insights into the mechanisms of ISP loading on SEC in the LAA. Abstract Figure.

Simultaneous occurrence of accelerated nodulosis in lungs, liver, and kidneys, and acute exacerbation of interstitial pneumonia in a patient with rheumatoid arthritis: an autopsy case report

Background

Accelerated nodulosis (ARN) is a rare variant of rheumatoid nodules (RNs) that is characterized by a rapid onset or the worsening of RNs. It generally develops at the fingers in patients with rheumatoid arthritis (RA) receiving methotrexate (MTX). Few case reports have described ARN at an extracutaneous location.

Case presentation

An elderly patient with long-standing RA was admitted to our hospital with acute respiratory failure. Computed tomography upon admission showed diffuse ground-glass opacities superimposed with subpleural reticular shadowing and honeycombing and multiple nodules in the lungs and liver. Despite the discontinuation of MTX and introduction of an immunosuppressive regimen with pulse methylprednisolone followed by a tapering dose of prednisolone and intravenous cyclophosphamide, the patient died due to the acute exacerbation (AE) of RA-related interstitial lung disease (ILD) following the parallel waxing and waning of a diffuse interstitial shadow and pulmonary and liver nodules. At autopsy, RNs were scattered throughout both lung fields in addition to extensive interstitial changes. RNs were also detected in the liver and kidneys. The foci of cryptococcosis were mainly identified in alveolar spaces. Based on the clinical and pathological findings, these nodules were most consistent with ARN because of acute increases in the size and number of previously detected pulmonary nodules.

Conclusion

The present case is noteworthy because ARN was concurrently detected in multiple internal organs and may be associated with the AE of RA-related ILD.

Orbital Intravascular Natural Killer/T-cell Lymphoma: An Unusual Cause of Ocular Symptoms

Orbital intravascular lymphoma is rare and typically of B-cell lineage. In this study, we report a patient who developed orbital lesions of intravascular natural killer/T-cell lymphoma (IVNKL), an extremely rare lymphoma. An 88-year-old man presented with rapidly progressive right vision loss and double vision. A neurological examination revealed that he had decreased visual acuity and severe oculomotor impairment in the right eye. Magnetic resonance imaging showed right-dominant, nonmass lesions in both orbits. No lesions were found in the lymph nodes, skin, or brain. The patient received immunosuppressive and antifungal therapy, but his clinical condition rapidly deteriorated, and he died of multiple organ failure. Autopsy revealed natural killer/T-cell lymphoma proliferation within the lumina of small blood vessels in multiple organs, including the ocular adnexa of the right orbit. These findings show that he was ultimately diagnosed with IVNKL. IVNKL could initially cause ocular symptoms due to the involvement of the ocular adnexa. Ocular involvements have not been described previously. Even if patients initially present with only ocular symptoms, IVNKL should be considered.

Validity of a model using routinely collected data for identifying infections following gastric, colorectal, and liver cancer surgeries

PURPOSE

Validating outcome measures is a prerequisite for using administrative databases for comparative effectiveness research. Although the Japanese Diagnosis Procedure Combination database is widely used in surgical studies, the outcome measure for postsurgical infection has not been validated. We developed a model to identify postsurgical infections using the routinely-collected Diagnosis Procedure Combination data.

METHODS

We retrospectively identified inpatients who underwent surgery for gastric, colorectal, or liver cancer between April 2016 and March 2018 at four hospitals. Chart reviews were conducted to identify postsurgical infections. We used bootstrap analysis with backwards variable elimination to select independent variables from routinely-collected diagnosis and procedure data. Selected variables were used to create a score predicting the chart review-identified infections, and the performance of the score was tested.

RESULTS

Among the 756 eligible patients, 102 patients (13%) had postoperative infections. Three variables were identified as predictors: diagnosis of infectious disease recorded as a complication arising after admission, addition of an intravenous antibiotic, and bacterial microscopy or culture. The prediction model had a C-statistic of 0.891 and pseudo-R² of 0.380. A cut-off of 1 point of the score showed a sensitivity of 92% and specificity of 71%, and a cut-off of 2 points showed a sensitivity of 77% and specificity of 91%.

CONCLUSIONS

Our model using routinely-collected administrative data accurately identified postoperative infections. Further external validation would lead to the application of the model for research using administrative databases. This article is protected by copyright. All rights reserved.

Effects of an elemental diet to reduce adverse events in patients with esophageal cancer receiving docetaxel/cisplatin/5-fluorouracil: a phase III randomized controlled trial-EPOC 2 (JFMC49-1601-C5)

Background

Oral mucositis (OM) is an unpleasant adverse event in patients receiving chemotherapy. A prospective feasibility study showed that elemental diet (ED), an oral supplement that does not require digestion, may prevent OM. Based on this, we established a central review system for oral cavity assessment by dental oncology specialists blinded to background data. We used this system to elucidate the preventive effect of an ED against OM in patients with esophageal cancer receiving docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy.

Patients and methods

In this phase III, multicenter, parallel-group, controlled trial, patients consuming a normal diet orally were randomly assigned (1 : 1) to receive two cycles of DCF with (group A) or without (group B) an ED (Elental® 160 g/day). We assessed the incidence of grade ≥2 OM evaluated by two reviewers, changes in body weight, prealbumin, C-reactive protein, and DCF completion rate based on ED compliance.

Results

Of the 117 patients randomly assigned to treatment, four failed to start treatment and were excluded from the primary analysis; thus, groups A and B comprised 55 and 58 patients, respectively. There were no significant differences in background characteristics. Grade ≥2 OM was observed in eight (15%) and 20 (34%) patients in groups A and B, respectively (P = 0.0141). Changes in body weight and prealbumin during the two DCF cycles were significantly higher in group A than B (P = 0.0022 and 0.0203, respectively). During the first cycle, changes in C-reactive protein were significantly lower in group A than B (P = 0.0338). In group A (receiving ED), the DCF completion rate was 100% in patients with 100% ED compliance and 70% in patients failing ED completion (P = 0.0046).

Conclusions

The study findings demonstrate that an ED can prevent OM in patients with esophageal cancer receiving chemotherapy.

•

Patients receiving docetaxel, cisplatin, and 5-fluorouracil (DCF) chemotherapy commonly develop oral mucositis (OM).

•

An elemental diet (ED) was able to prevent OM in patients with esophageal cancer receiving DCF.

•

Grade ≥2 OM was observed in 15% of patients receiving the ED versus 34% of those not receiving the ED (P = 0.0141).

•

Body weight was maintained in the ED group, and hematologic toxicities were lower, compared with the non-ED group.

•

The DCF completion rate significantly correlated with ED compliance (P = 0.0046).

[Idiopathic Intrapulmonary Hematoma Need to Differentiate from Pulmonary Metastasis of Malignant Melanoma:Report of a Case]

A 74-year-old man had previously been treated for primary malignant melanoma of the bladder. Three years after surgery, 8 mm round nodule in the right lower lobe was found on chest computed tomography. The nodule increased to 11 mm after three months, and resected with a diagnosis of metastatic malignant melanoma. By pathology, it was diagnosed as an intrapulmonary hematoma.

Dietary arachidonic acid improves age-related excessive enhancement of the stress response

OBJECTIVE

The aim of this study is to understand whether the responsiveness of the hypothalamic-pituitary-adrenal (HPA) axis to stress increases excessively with aging in senescence-accelerated mice-prone 10 (SAMP10) and to investigate the role of arachidonic acid (ARA) in this process.

MATERIALS AND METHODS

The area under the curve of CORT concentration (CORT-AUC), an index of the HPA axis responsiveness to stress, was assessed in SAMP10 subjected to a 30-minute restraint stress up to 120 minutes after the restraint stress onset. Furthermore, the HPA axis responsiveness was evaluated in aged SAMP10 fed 0.4% ARA-containing diet (ARA group) or control diet (CON group) for 4 weeks. Three weeks later, these mice were divided into a group with a 30-minute restraint stress (CON-S or ARA-S group) and a group without restraint stress (CON-NS or ARA-NS group). Hippocampi were collected after stress release and fatty acid and glucocorticoid receptor (GR) protein levels were evaluated in the nucleus and cytosol.

RESULTS

The CORT-AUC of aged SAMP10 was 21% significantly higher than that of young SAMP10. In the ARA group, hippocampal ARA was 0.5% significantly higher than that in the CON group. CORT-AUC in the ARA group was 24% significantly lower than that in the CON group. The ratio of GR protein levels in the nucleus and cytosol in the ARA-S group was 1.72 times significantly higher than that in the ARA-NS group but no difference was observed between the CON-S and CON-NS groups.

CONCLUSIONS

Dietary ARA seems to suppress age-related excessive enhancement of the HPA axis responsiveness via attenuation of age-related decline in hippocampal GR translocation into the nucleus after stress loading, which may contribute to an improvement of mental health.

A practical system that enables physicians to respond expeditiously to significant unexpected findings (SUFs) in radiological reports

PURPOSE

To demonstrate effectiveness of our present radiological report check flowchart enabling physicians to respond to significant unexpected findings (SUFs), by comparing the response periods from the examination date to the action date on untreated SUFs between the previous and present versions of our flowchart.

METHODS

In the flowchart's previous version used February-October 2019, SUFs, which were notified by email, were audited every month. The physician received a phone call and was asked to act on the untreated SUF. In the flowchart's present version used from November 2019 to May 2020, SUFs were audited every 2 weeks. The physician and his/her chief were asked to return a written response to the untreated SUF. We evaluated the difference in the response periods between the previous and present versions of the flowchart.

RESULTS

With the previous flowchart's use, untreated SUFs were 43 of 229 SUFs (18.8%) with the present flowchart untreated SUFs were 22 of 130 SUFs (16.9%). All SUFs in both periods were eventually responded. The present flowchart (median/range, 25/11-70 days) significantly had shorter response periods than the previous flowchart (70/16-290 days) (p < 0.0001).

CONCLUSION

The present flowchart employing a shortened primary audit interval, a written response, and the department chief's intervention, helped reduce the response periods.

Comparison of intra-wound drainage tubes after cardiac surgery: Blake drains versus Multichannel drains

BACKGROUND

Blake and Multichannel drains have been used in our department. Although both are made up of silicone, they differ in structure. We investigated the drainage effects of these two types of drains and the factors related to their occlusion.

METHODS

We enrolled 100 consecutive cases (50 using Blake drains and 50 using Multichannel drains) of cardiovascular surgery performed in our department from July 2017 to April 2018. The formation of thrombi in the groove and tube of the drains was evaluated in each case. The tube portion was checked for the presence of occlusion, and the groove portion was examined for the number and ratio of thrombi formed in the grooves.

RESULTS

The clot formation rate in the groove part was slightly higher in the Multichannel cases than in the Blake cases. In addition, analysis within the Multichannel cases revealed that the thrombus formation rate between the catheter lumen and the three grooves (without the catheter lumen) was significantly different, with the highest groove clot formation rate occurring in the catheter lumen. Out of 34 cases of occlusions, there were 26 cases (52%) of Multichannel drains, and only 8 cases (16%) of Blake drains (p < 0.01). A multiple logistic regression analysis revealed that the most important contributory factor in tube obstruction was the drain type.

CONCLUSIONS

The catheter lumen of the Multichannel drain was more susceptible to thrombus formation than the groove. The tube part of the Multichannel drain was more prone to occlusion than that of the Blake drain.

Association of Education and Depressive Symptoms with Tooth Loss

Previous evidence suggests the association of lower educational attainment and depressive symptoms with tooth loss. The hypothesis of this study was that these factors may exacerbate the effect on tooth loss beyond the sum of their individual effects. We aimed to clarify the independent and interactive effects of educational attainment and depressive symptoms on the number of missing teeth among community residents. Cross-sectional data of 9,647 individuals were collected from the general Japanese population. Dental examination was conducted by dentists. Educational attainment was categorized into 3 levels based on the number of educational years: ≤9, >9 to ≤12, and >12 y. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to assess depressive symptoms; a total score of ≥16 and/or the use of medications for depression indicate the presence of depressive symptoms. In the multivariate analysis with adjustment for conventional risk factors, educational attainment was identified as a determinant of the number of missing teeth (>9 to ≤12 y of education: coefficient = 0.199, 95% confidence interval [CI], 0.135 to 0.263, P < 0.001; ≤9 y of education: coefficient = 0.318, 95% CI, 0.231 to 0.405, P < 0.001: reference, >12 y of education). An analysis that included interaction terms revealed that the relationship between "≤9 y of education" and the number of missing teeth differed depending on the depressive symptoms, indicating a positive interactive association (coefficient for interaction = 0.198; 95% CI, 0.033 to 0.364, P for interaction = 0.019: reference, >12 y of education). Our study suggests the presence of a significant association between educational attainment and tooth loss, as well as a partial interactive association between "≤9 y of education" and "depressive symptoms" in the general Japanese population.

Deep learning for screening of pulmonary hypertension using standard chest X-ray

Background

Early detection of pulmonary hypertension (PH) is crucial to ensure that patients receive timely treatment for the progressive clinical course. The chest X-ray (CXR), a routine method at hospitals, has recommended in order to reveal features supportive of a diagnosis of PH. However, it is well known that the sensitivity and specificity are low.

Purpose

We tested the hypothesis that application of artificial intelligence (AI) to the CXR could identify PH.

Methods

We retrospectively enrolled 900 data with paired CXR and right heart catheter (RHC), including the pulmonary artery pressure, from October 2009 to December 2018. We trained a convolutional neural network to identify patients with PH as actual value of pulmonary artery pressure, using the CXR alone (Figure). The diagnosis of PH was performed using hemodynamic measurements according to the most recent World Symposium standards: mean PAP ≥20 mmHg. We have compared the area under the curve (AUC) by human observers, measurements of CXR images, and AI for detection of PH.

Results

Subjects were divided into two groups with PH (439 patients; mean age, 66±14 years; 233 male) and without PH (461 patients; mean age, 68±12 years; 278 male). In an independent set, AI was the highest diagnostic ability for detection of PH (AUC: 0.71). The AUC by the AI algorithm was significantly higher than the AUC by measurements of CXR images and human observers (0.71 vs. 0.60 and vs. 0.63, all compared p&lt;0.05).

Conclusion

Applying AI to the CXR (a classical, universal, low-cost test) permits the CXR images to serve as a powerful tool to screen for PH.

Neural network

Funding Acknowledgement

Type of funding source: None

Surgical outcome of elective total arch replacement with coronary artery bypass grafting

Purpose

We aimed to compare the surgical outcome between total arch replacement with coronary bypass surgery and that without.

Methods

Between 2008 and 2016, 157 consecutive patients underwent total arch replacement with antegrade cerebral perfusion and moderate hypothermic circulatory arrest using the proximal first approach. They were divided into two groups: total arch replacement with coronary bypass surgery (group 1, n = 38) and that without (group 2, n = 119).

Results

Of the 38 patients in group 1, 37 (97%) were asymptomatic. The left internal thoracic artery and saphenous vein were used in one (2.6%) and 38 (100%) patients, respectively. The mean number of coronary anastomoses was 1.5 ± 1.0. In-hospital mortality rate was 3.8%. Cardiopulmonary bypass time and operation time in group 1 were significantly longer than those in group 2 (336 ± 52 min vs. 276 ± 38 min, P < 0.0001 and 702 ± 122 min vs. 619 ± 94 min, P < 0.0001, respectively). No differences in in-hospital mortality and perioperative myocardial infarction were found between the groups (5.3% vs. 3.4%, P = 0.633 and 0% vs. 1.7%, P = 1.000, respectively). In the multivariate analysis, age (odds ratio, 1.208; 95% confidence interval, 1.041-1.497; P = 0.008) and cardiopulmonary bypass time (odds ratio, 1.019; 95% confidence interval, 1.001-1.041; P = 0.041) were significant determinants of in-hospital mortality.

Conclusions

Although prolonged cardiopulmonary bypass time was a significant determinant of in-hospital mortality, total arch replacement with coronary bypass surgery could be safely performed with favorable outcomes.

Application of a Customized Total Talar Prosthesis for Revision Total Ankle Arthroplasty

BACKGROUND

The rate of revision surgery for total ankle arthroplasty (TAA) is higher than for hip and knee arthroplasties. Tibiotalocalcaneal arthrodesis is widely used; however, it requires a large allograft. Thus, the use of a customized total talar prosthesis in combination with the tibial component of TAA (combined TAA) may be an effective strategy for talar component subsidence. This study aimed to evaluate the clinical and radiographic effectiveness of the combined TAA in such revision cases.

METHODS

Between 2000 and 2015, 10 patients (10 women; 10 ankles) were treated using the combined TAA for revision after standard TAA or combined procedures that included the use of a talar body prosthesis. In 6 patients, the tibial component was concurrently replaced. The median follow-up period was 49 months (interquartile range [IQR], 24.5 to 90 months). The Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale score, a numerical rating scale (NRS) pain score, passive range of motion of the ankle, and the presence of osteophytes and degenerative changes in the adjacent joints were assessed preoperatively and at final postoperative follow-up.

RESULTS

The median NRS pain score improved significantly, from 7 (IQR, 6.25 to 8.75) to 2 (IQR, 1 to 3). The median JSSF ankle-hindfoot scale total score improved significantly, from 64 (IQR, 56.25 to 71.5) to 88.5 (IQR, 79.75 to 96). In the subcategories of this scale, the median pain score improved from 20 (IQR, 20 to 27.5) to 35 (IQR, 30 to 40), and the median function score improved from 34 (IQR, 26.5 to 37) to 43.5 (IQR, 39.75 to 46). The median range of motion improved from 29° (IQR, 25.5° to 35°) to 35° (IQR, 31.25° to 43.75°). No significant difference in osteophyte formation was found. Degenerative changes in the adjacent joint were found only in the talonavicular joint.

CONCLUSIONS

The combined TAA, used in revision for postoperative complications after standard TAA or combined procedures including the use of a talar body prosthesis, was associated with improved objective JSSF ankle-hindfoot scale scores, subjective pain assessment, and range of motion in the ankle.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.