Long- term outcomes of congenital tracheal stenosis after slide tracheoplasty

PURPOSE

Long-term outcomes of slide tracheoplasty in patients with congenital tracheal stenosis (CTS) have rarely been reported. This study aimed to clarify the long-term outcomes of CTS after slide tracheoplasty.

METHODS

The medical records of 33 patients who underwent slide tracheoplasty for CTS at our institution between January 2005 and July 2018, with a follow-up duration > 5 years, were retrospectively reviewed. Patients' characteristics, perioperative condition, operative management, postoperative course, tracheal stenosis rates and growth data, were collected from medical records.

RESULTS

The median operative age, minimum tracheal diameter, length of stenosis, duration of hospital stays, and follow-up duration were 8 months, 2.4 mm, 35 mm, 39 days, and 90 months, respectively. One patient died of bleeding in the right lung at 126 months postoperatively. Among the 10 patients requiring postoperative tracheostomy, seven were successfully decannulated at a median of 65 months postoperatively. Tracheal stenosis rates improved postoperatively and were subsequently maintained. Growth impairment and psychomotor delay were observed in 9 and 16 patients, respectively with significant differences found only in cases with genetic abnormalities and not in tracheal stenosis severity.

CONCLUSION

Slide tracheoplasty for CTS leads to favorable long-term outcomes. However, various associated anomalies may influence growth and psychomotor development, emphasizing the importance of adequate support.

Observation of an exotic insulator to insulator transition upon electron doping the Mott insulator CeMnAsO

A promising route to discover exotic electronic states in correlated electron systems is to vary the hole or electron doping away from a Mott insulating state. Important examples include quantum criticality and high-temperature superconductivity in cuprates. Here, we report the surprising discovery of a quantum insulating state upon electron doping the Mott insulator CeMnAsO, which emerges below a distinct critical transition temperature, TII. The insulator-insulator transition is accompanied by a significant reduction in electron mobility as well as a colossal Seebeck effect and slow dynamics due to decoupling of the electrons from the lattice phonons. The origin of the transition is tentatively interpreted in terms of many-body localization, which has not been observed previously in a solid-state material.

Incidence of congenital tracheal stenosis in left pulmonary artery sling diagnosed by bronchoscopy

PURPOSE

Congenital tracheal stenosis (CTS) has been reported to occur in 50-65% of cases of left pulmonary artery sling (LPAS), but the exact incidence rate is unknown. This study aimed to determine the actual rate using bronchoscopy and to elucidate morphological features in computed tomography (CT) diagnosis.

METHODS

We performed a single institutional retrospective review of all patients with LPAS between January 2010 and March 2022. The percentage of complete tracheal rings in patients with LPAS was evaluated using bronchoscopy. The anteroposterior/lateral diameter ratios at the smallest and largest diameters of each CTS patient's trachea were measured on CT. The Wilcoxon signed-rank test was used to analyze the differences between the two parts.

RESULTS

Fifty-two patients with LPAS were enrolled. All patients had complete tracheal rings on bronchoscopy. CT analysis of 32 patients with CTS was performed. The median anteroposterior/lateral diameter ratio at the smallest diameter was 1.05 (interquartile range [IQR] 0.95-1.15); the median ratio at the largest diameter was 0.94 (IQR 0.89-0.99). There was a significant difference between the two parts (p = 0.013).

CONCLUSION

CTS might be universally associated with LPAS. The circular tracheal cross-section on CT might imply the existence of a complete tracheal ring.

Clinical features of a tracheoesophageal fistula associated with complete tracheal rings

PURPOSE

A tracheoesophageal fistula (TEF) associated with complete tracheal rings (CTR) is extremely rare. This study aimed to elucidate the clinical features of this combination.

METHODS

Records of 39 patients diagnosed with TEF with or without CTR between January 2013 and February 2023 were retrospectively reviewed. Data collected included location of the TEF and CTR, esophageal gap, surgery of TEF/esophageal atresia (EA), and symptoms of CTR.

RESULTS

Seven patients had CTR, while 32 patients did not have CTR. TEF was frequently located higher than the T4 vertebra, and the median esophageal gap was shorter in patients with CTR than in those without (5/7 [71.4%] vs. 6/32 [18.8%], P = 0.012; 0 (range: 0-15) mm vs. 13.3 (range: 0-40) mm, P = 0.017, respectively). TEF was located just above the beginning of the CTR in all patients. All patients with CTR underwent primary esophageal anastomosis. Additionally, two patients were diagnosed with CTR before TEF/EA repair. A tracheal tube was prevented from contacting the CTR during TEF/EA repair, and respiratory insufficiency did not occur.

CONCLUSIONS

Our results may help pediatric surgeons in the management of TEF with CTR.

Quality of life after type-A esophageal atresia surgery: changes over time and effect of pre-anastomotic elongation

AIM

To assess mid-/long-term postoperative quality of life (QOL) of esophageal atresia (EA) patients.

METHODS

Modified gastrointestinal quality-of-life index surveys were administered to postoperative EA patients who were at least 7 years old at evaluation to assess three topics about general lifestyle (GL), five topics about EA, and four topics about mental health (MH). For MH, caregivers were also interviewed, but separately. Subjects were divided according to age: children (7-12 years old), teenagers (13-19), and adults (20 and over) and compared according to Foker or Kimura elongation (FK) or bougienage stretching (BS).

RESULTS

There were 22 patients evaluated. Responses for GL, EA, and MH did not differ significantly between age groups, but MH responses by caregivers for subjects who were children or teenagers scored significantly lower than responses they made themselves. For primary esophageal elongation technique (PET), age at esophagoesophagostomy was significantly higher in FK. Despite FK scoring 15.1 versus 12.4 for BS during EA evaluation, this difference was not statistically significant.

CONCLUSION

Changes in QOL responses according to age were unremarkable. However, discrepancies in MH indicate that subjects felt better than their caregivers thought. PET did not appear to influence QOL.

Spindle cell sarcoma with KIAA1549-BRAF resembling infantile fibrosarcoma morphologically: A case report and literature review

Infantile fibrosarcoma (IFS) commonly harbors ETS variant transcription factor 6 (ETV6)-neurotrophic receptor tyrosine kinase 3 (NTRK3) fusion. However, the recent accessibility to clinical next-generation sequencing (NGS) has revealed ETV6-NTRK3 negative spindle cell sarcomas resembling IFS morphologically, involving NTRK1/2, MET, RET and BRAF. The present report describes a pediatric case of spindle cell sarcoma with KIAA1549-BRAF resembling IFS morphologically. A 20-month-old female patient was referred to Kobe Children's Hospital (Kobe, Japan) for the treatment of intrathoracic spindle cell sarcoma. Pathologically, the intrathoracic tumor cells were composed of spindle cells with focal hemagiopericytomatous pattern. In immunohistochemistry analysis, the intrathoracic tumor cells focally expressed desmin and WT-1 and were negative for pan-tropomyosin receptor kinase (TRK), S-100 and CD34. Fluorescence in situ hybridization analysis for ETV6 and capicua transcriptional repressor revealed negative split signals. Although the patient was initially diagnosed with IFS morphologically, KIAA1549-BRAF fusion transcript was detected by comprehensive genomic profiling with NGS using intrathoracic tumor tissues and confirmed by reverse transcription-PCR. Chemotherapy induced a reduction in the tumor size. At present, the patient is alive with the disease and has been receiving therapy for 8 months since the initiation of chemotherapy. Review of BRAF-altered spindle cell sarcomas resembling IFS morphologically revealed the inconsistency in immunohistochemical expression patterns and the diversity of BRAF fusion genes and mutations. Therefore, the elucidation of genomic profiling by NGS may assist in making an appropriate diagnosis and selecting novel alternative therapies in ETV6-NTRK3-negative spindle cell sarcomas resembling IFS morphologically.

Closed-PICU perioperative management of congenital tracheal stenosis

BACKGROUND

Perioperative management of congenital tracheal stenosis (CTS) is challenging. In the present study, compared the effect of closed-pediatric intensive care unit (PICU) perioperative management by pediatric intensivists and open-PICU management by surgeons. Outcomes in terms of ventilator-free days (VFD) and length of postoperative PICU stay in children with CTS were evaluated.

METHODS

This retrospective cohort study was conducted in a PICU in Japan. Children with CTS who underwent slide tracheoplasty were grouped according to whether they were perioperatively managed in an open (January 2015 to April 2016) or a closed (May 2016 to August 2019) PICU. Data were extracted from patients' medical records.

RESULTS

In total, 13 and 38 patients were included in the open- and closed-PICU groups, respectively. Compared to the open-PICU group, the closed-PICU group had shorter duration of muscle relaxant administration (median 4 vs 5 days; P < 0.001), earlier enteral nutrition (34/38 [90%] vs 1/13 [8%]; P < 0.001), more 28-day VFD (median 21 vs 20 days; P = 0.04), and shorter duration of postoperative PICU stay (median 16 vs 36 days; P = 0.002), but mortality did not differ significantly between the two groups (0/38 [0%] vs 1/13 [8%]; P = 0.25).

CONCLUSIONS

Closed-PICU perioperative management with pediatric intensivists' participation significantly increased 28-day VFD and reduced the length of postoperative PICU stay in patients with congenital tracheal stenosis.

Hemi-Clamshell Approach for Fetal Lung Interstitial Tumor Resection in a Neonate: A Case Report

Fetal lung interstitial tumor (FLIT) is a rare primary lung mass in neonates. Classical incisions, such as posterolateral thoracotomy or median sternotomy, do not provide optimal exposure of the operative field for the resection of pediatric thoracic giant tumors. Herein, we report a rare case of a FLIT in a full-term male neonate, with complete resection achieved using a hemi-clamshell approach, which provided the required visualization of the operative field. The neonate was transferred to our hospital because of mild respiratory distress, which developed 18-hour after normal vaginal delivery. A mass in his right chest, without a midline shift, was observed on chest radiographs. Computed tomography showed a well-circumscribed solid anterior cervicothoracic mass, with a uniform density and no apparent cysts, diagnosed as a primary thoracic giant tumor. Once the patient was clinically stabilized, we proceeded with right upper lobectomy, using a hemi-clamshell approach, full sternotomy, and anterolateral thoracotomy, on postnatal day 22.

Histopathologic examination revealed an 8.5 × 6.5 × 4.0 cm solid mass within the right upper lobe, which was diagnosed as a FLIT. His postoperative recovery was uneventful. The patient was followed up for 1 year, with no complaints or symptoms and no postoperative shoulder dysfunction. Gross total resection of primary thoracic giant tumors can be accomplished in neonates with optimal exposure of the chest cavity using a hemi-clamshell approach.

Infectious complications after tracheoplasty for congenital tracheal stenosis: a retrospective comparative study

PURPOSE

The factors related to infectious complications after tracheoplasty for congenital tracheal stenosis (CTS) remain unclear; we, therefore, assessed these factors in this study.

METHODS

We divided 47 patients who underwent slide tracheostomy and tracheal resection for CTS between May 2016 and December 2020 into an infected group and a non-infected group. Their characteristics were compared between groups. Results are presented as the median (range) or incidence.

RESULTS

Infectious complications were observed in 12 patients (25.5%). Empyema and mediastinitis were seen in 5 cases (10.6%). There was a significant difference in the following factors in the infected and non-infected groups, respectively: weight, 5457 (2868-20,750) g and 6554 (2275-20,800) g (p = 0.025); surgical time, 575.5 (313-646) min and 349 (270-651) min (p < 0.001); extracorporeal circulation time, 303.5 (186-610) min and 216 (117-478) min (p = 0.001); and postoperative intubation time, 13 (7-28) days, and 6 (5-22) days (p < 0.001). Age, malnutrition, cardiovascular comorbidities, and preoperative methicillin-resistant Staphylococcus aureus detection were not significantly different between the two groups.

CONCLUSION

There were a few serious infectious complications and no perioperative deaths. Attention should be paid to low body weight, long surgical and extracorporeal circulation time, and intubation time in relation to infectious complications.

Virtual magnetic resonance lumbar spine images generated from computed tomography images using conditional generative adversarial networks

INTRODUCTION

The aim of this study was to generate virtual Magnetic resonance (MR) from computed tomography (CT) using conditional generative adversarial networks (cGAN).

METHODS

We selected examinations from 22 adults who obtained their CT and MR lumbar spine examinations. Overall, 4 examinations were used as test data, and 18 examinations were used as training data. A cGAN was trained to generate virtual MR images from the CT images using the corresponding MR images as targets. After training, the generated virtual MR images from test data in epochs 1, 10, 50, 100, 500, and 1000 were compared with the original ones using the mean square error (MSE) and structural similarity index (SSIM). Additionally, two radiologists also performed qualitative assessments.

RESULTS

The MSE of the virtual MR images decreased as the epoch of the cGANs increased from the original CT images: 8876.7 ± 1192.9 (original CT), 1567.5 ± 433.9 (Epoch 1), 1242.4 ± 442.0 (Epoch 10), 1065.8 ± 478.1 (Epoch 50), 1276.1 ± 718.9 (Epoch 100), 1046.7 ± 488.2 (Epoch 500), and 1031.7 ± 400.0 (Epoch 1000). No considerable differences were observed in the qualitative evaluation between the virtual MR images and the original ones, except in the structure of the spinal canal.

CONCLUSION

Virtual MR lumbar spine images using cGANs could be a feasible technique to generate near-MR images from CT without MR examinations for evaluation of the vertebral body and intervertebral disc.

IMPLICATIONS FOR PRACTICE

Virtual MR lumbar spine images using cGANs can offer virtual CT images with sufficient quality for attenuation correction for PET or dose planning in radiotherapy.

Association between blood pressure classification using the 2017 American College of Cardiology/American Heart Association blood pressure guideline and hypertensive retinopathy

Purpose

We aimed to explore the association of blood pressure (BP) classification using the 2017 American College of Cardiology/ American Heart Association Guideline and the prevalence of hypertensive retinopathy using a nationwide epidemiological database.

Methods

This study is a retrospective observational cross-sectional analysis using the health claims database of the JMDC between 2005 and 2020. We analyzed 280,599 participants who did not take anti-hypertensive medications. Each participant was categorized as having normal BP (systolic BP [SBP] &lt;120 mm Hg and diastolic BP [DBP] &lt;80 mm Hg; n=159,524); elevated BP (SBP 120–129 mm Hg and DBP &lt;80 mm Hg; n=35,603); stage 1 hypertension (SBP 130–139 mm Hg or DBP 80–89 mm Hg; n=54,795); or stage 2 hypertension (SBP ≥140 mm Hg or DBP ≥90 mm Hg; n=30,677). Retinal photography at health check-up was classified as normal, grade 1, grade 2, grade 3, or grade 4 according to the Keith-Wagener-Barker system.

Results

Median (interquartile range) age was 46 (40–53) years, and 50.4% were men. Hypertensive retinopathy which was defined as ≥ Keith-Wagener-Barker system grade 1, was observed in 16,836 participants (6.0%). Multivariable logistic regression analysis showed that, compared with normal BP, elevated BP (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.23–1.38), stage 1 hypertension (OR 1.71, 95% CI 1.64–1.79), and stage 2 hypertension (OR 4.10, 95% CI 3.93–4.28) were associated with higher prevalence of hypertensive retinopathy. Even among 92,121 participants without obesity, high waist circumference, diabetes mellitus, dyslipidemia, cigarette smoking, and alcohol drinking, multivariable logistic regression analysis showed that, compared with normal BP, elevated BP (odds ratio 1.34, 95% CI 1.19–1.51), stage 1 hypertension (OR 1.79, 95% CI 1.61–1.98), and stage 2 hypertension (OR 4.42, 95% CI 4.00–4.92) were associated with higher prevalence of hypertensive retinopathy. The association between BP category and hypertensive retinopathy was observed in all subgroups stratified by age or sex.

Conclusion

Our investigation showed that the prevalence of hypertensive retinopathy increased with the blood pressure category, suggesting that atherosclerotic change could start even in elevated BP and stage 1 hypertension.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and H30-Policy-Designated-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141).

Breast cancer surgery in patients with schizophrenia: short-term outcomes from a nationwide cohort

BACKGROUND

Although patients with schizophrenia have a higher risk of developing breast cancer than the general population, studies that have investigated postoperative complications after breast cancer surgery in patients with schizophrenia are scarce. This study examined associations between schizophrenia and short-term outcomes following breast cancer surgery.

METHODS

Patients who underwent surgery for stage 0-III breast cancer between July 2010 and March 2017 were identified from a Japanese nationwide inpatient database. Multivariable analyses were conducted to compare postoperative complications and hospitalization costs between patients with schizophrenia and those without any psychiatric disorder. Three sensitivity analyses were performed: a 1 : 4 matched-pair cohort analysis with matching for age, institution, and fiscal year at admission; analyses excluding patients with schizophrenia who were not taking antipsychotic medication; and analyses excluding patients with schizophrenia who were admitted to hospital involuntarily.

RESULTS

The study included 3660 patients with schizophrenia and 350 860 without any psychiatric disorder. Patients with schizophrenia had a higher in-hospital morbidity (odds ratio (OR) 1.37, 95 per cent c.i. 1.21 to 1.55), with more postoperative bleeding (OR 1.34, 1.05 to 1.71) surgical-site infections (OR 1.22, 1.04 to 1.43), and sepsis (OR 1.20, 1.03 to 1.41). The total cost of hospitalization (coefficient €743, 95 per cent c.i. 680 to 806) was higher than that for patients without any psychiatric disorder. All sensitivity analyses showed similar results to the main analyses.

CONCLUSION

Although causal inferences remain premature, multivariable regression analyses showed that schizophrenia was associated with greater in-hospital morbidity and higher total cost of hospitalization after breast cancer surgery than in the general population.

Histological features of complete tracheal rings in congenital tracheal stenosis

PURPOSE

Congenital tracheal stenosis is a disease in which complete tracheal cartilage rings (CTCR) cause airway narrowing. Although tracheal cartilage malformation has been suggested as a cause of CTCR, no histological studies have been performed. Here, we report a comparison of the tissues from CTCR and normal tracheal cartilage.

METHODS

Thirty-one infants who underwent slide tracheoplasty at our institution from May 2016 to August 2019 were included. Tissues from ten autopsy cases without tracheal lesions were used as controls. The survey items were tracheal cartilage cell density, cartilage thickness, and chondrocyte findings.

RESULTS

The median cartilage cell density from cases was 23/125 × 125 µm² and from controls was 23.5/125 × 125 µm² (p = 0.90). The median cartilage thickness from cases was 689 µm and from controls was 840 µm (p = 0.11). Comparing the ventral and dorsal sides of the CTCR tissues, the cell density was significantly different (median ventral 23/125 × 125 µm²; median dorsal 19.5/125 × 125 µm²; p = 0.034). There were no significant findings in the chondrocytes of the CTCR tissues.

CONCLUSION

CTCR tissues did not differ in cartilage density and thickness from normal tracheal cartilage.

Epithelial and ganglionic distribution at the distal rectal end in anorectal malformations: could it play a role in anastomotic adaptation?

PURPOSE

In anorectal malformations (ARMs), the epithelium of the distal rectal end is not well described. We histomorphologically evaluated epithelial and ganglionic distribution in the distal rectal end of ARMs resected during anorectoplasty to assess similarities and differences with normal anal canal structure.

METHODS

In this single-center retrospective study, specimens from 60 ARM patients (27 males, 33 females) treated between 2008 and 2019 were evaluated.

RESULTS

Epithelium type and alignment sequence as well as ganglionic distribution were similar in the distal rectal end and in a normal anal canal. Stratified columnar epithelium (anal transitional zone, ATZ) was seen in 49/60 (81.7%) cases and in all ARM types, including the no-fistula type. Anal crypts were identified in the stratified columnar epithelium (ATZ) of 46/49 (93.9%) patients. Regarding distal rectal end-resecting anorectoplasty, in 90% of patients, resection was performed distal to the Herrmann line. Ganglion cell distribution was exclusively proximal to the Herrmann line.

CONCLUSION

Epithelial and ganglionic distribution was similar in the distal rectal end of ARMs and in a normal anal canal. The ATZ is the epithelial boundary between the rectum and skin in a normal anal canal. ATZ preservation could reproduce anal canal structure in ARM reconstruction.

The Double Burden of COVID-19 and Dengue in Nepal: The challenges ahead

Coronavirus disease 2019 (COVID-19) pandemic has caused significant impact on the health care system. As a consequence, diagnosis and treatment of vector borne diseases including dengue has been equally affected. Nepal is no exception to this, where COVID-19 cases is exponentially increased and all resources are concentrated on its prevention, control and management. Dengue, one of the major vector-borne diseases in Nepal, is apparently overlooked despite approaching the peak season of the disease. The aim of this paper is to describe the double burden of COVID-19 and dengue in Nepal, particularly highlighting the co-circulation and possible coinfections. This has posed higher risk of increased severity, more severe cases and deaths in Nepal. Moreover, potential misdiagnosis of these viral diseases may lead to delayed or, inappropriate treatment and poor allocation of resources.

Geographic variation in the outcome of patients hospitalized for heart failure: analysis of a nationwide inpatient database

Background

The prevalence of heart failure (HF) is increasing in developed countries. Considering the significant socioeconomic burden of HF, nationwide actions against HF are indispensable. To that end, relevant information on regional variations among HF patients are required.

Purpose

We aimed to explore the geographic variations in the characteristics and outcomes of hospitalized HF patients using a nationwide inpatient database.

Methods and results

Using the Diagnosis Procedure Combination database which is a nationwide inpatient database in Japan, we carried out a comprehensive analysis of 447,818 hospitalized patients with HF (median age 81 years, 238,192 men) who were admitted between January 2010 and March 2018 in Japan. We divided the study population into seven geographical regions based on the location of the admitted hospital. Background characteristics were almost similar among all seven regions. The implementation rates of intubation, hemodialysis, inotropic agent, and advanced circulatory supports including intra-aortic balloon pumping and extracorporeal membrane oxygenation varied among the seven regions. There was a significant difference in the length of hospital stay and the in-hospital mortality among the seven regions. The multivariable logistic regression analysis including baseline clinical charasteristics and medication administered within two days after hospital admission fitted with a generalized estimation equation for in-hospital mortality showed that there was still a significant difference in the in-hospital mortality among the seven regions (Table).

Conclusion

The analysis of a nationwide inpatient database showed that geographical variations existed regarding the outcomes of patients hospitalized for HF. This suggests the necessity of further efforts to establish a standardized medical care system in this era of HF pandemic.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Grants from the Ministry of Health, Labour and Welfare, Japan (19AA2007 and H30-Policy-Designated-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141)

Correction to: Two infant cases of intraperitoneal arterial hemorrhage due to a duplication cyst: a case report

An amendment to this paper has been published and can be accessed via the original article.

Two infant cases of intraperitoneal arterial hemorrhage due to a duplication cyst: a case report

Background

Intraperitoneal arterial hemorrhage without trauma is extremely rare. We report two infant cases of intraperitoneal arterial hemorrhage due to intestinal duplication.

Case presentation

In case 1, a 2-month-old girl experienced sudden intraperitoneal hemorrhage from the middle colic artery with no apparent trauma. Hemostasis was achieved with suturing of the hemorrhage point, but the cause of hemorrhage was still unknown. Computed tomography after the first operation revealed a duodenal duplication cyst and a pseudopancreatic cyst. Percutaneous drainage of the pseudopancreatic cyst was performed, and the contents had high pancreatic amylase. As the size of the duodenal duplication cyst also decreased with this drainage, we suspected that the duodenal duplication cyst was connected to the pseudopancreatic cyst and the arterial hemorrhage. We hypothesized that the pancreatic juice inside the duplication cyst leaked into the intraperitoneal cavity and caused rupture of the arterial wall. Therefore, marsupialization of the duodenal duplication was performed to evacuate the pancreatic juice contained in the cyst toward the native duodenum. The postoperative course was uneventful.

In case 2, a 6-month-old boy experienced sudden intraperitoneal hemorrhage without trauma. The hemorrhage site was identified as the ileocecal artery, and hemostasis was achieved with sutures. Tissue near the hemorrhage point was biopsied, because the cause of arterial wall rupture was still unknown. The biopsied tissue was found to be intestinal mucosa. The patient had recurrent abdominal pain after the first operation, and computed tomography showed a duplication cyst located near the hemorrhage point. Therefore, we resected the intestinal duplication. Pathology results showed that the intestinal duplication contained intestinal mucosa, ectopic gastric mucosa, and pancreatic tissue. The postoperative course was uneventful.

Conclusion

Intraperitoneal arterial hemorrhage without trauma is an extremely rare condition, and identifying its cause is difficult. To our knowledge, this is the first report of intraperitoneal arterial hemorrhage due to intestinal duplication. In cases of unexplained intraperitoneal arterial hemorrhage in infants, intestinal duplication near the hemorrhage point should be suspected.

In vitro-in vivo extrapolation of metabolic clearance using human liver microsomes: factors showing variability and their normalization

In vitro-in vivo extrapolation (IVIVE) using human liver microsomes has been widely used to predict metabolic clearance, but some of the factors used in the process of prediction show variability for the same compound: notably, microsomal intrinsic clearance values corrected by the unbound fraction (CL_{int, u}), physiological parameters used for scale-up, and the source of in vivo clearance data.The purpose of this study was to assess the correlation between in vitro and in vivo CL_int with a focus on factors showing variability using four cytochrome P450 (CYP)3A substrates.We surveyed in vivo clearance values in literature and also determined the microsomal CL_{int, u} values. A scaling factor (SF_direct) was defined as in vivo CL_int divided by the microsomal CL_{int, u}, which ranged from 1190 to 2310 (mg protein per kg body weight). The application of a mean SF_direct of 1600 (mg protein per kg body weight) and further normalization by the microsomal CL_{int, u} values of midazolam, the most commonly used substrate, resulted in improved prediction accuracy for CL_{int, u} values from various microsomal batches.The results suggest the normalization of variability might be useful for predicting the in vivo CL_int.

Study of Quasielastic Barrier Distributions as a Step towards the Synthesis of Superheavy Elements with Hot Fusion Reactions

The excitation functions for quasielastic scattering of ^{22}Ne+^{248}Cm, ^{26}Mg+^{248}Cm, and ^{48}Ca+^{238}U are measured using a gas-filled recoil ion separator. The quasielastic barrier distributions are extracted for these systems and are compared with coupled-channel calculations. The results indicate that the barrier distribution is affected dominantly by deformation of the actinide target nuclei, but also by vibrational or rotational excitations of the projectile nuclei, as well as neutron transfer processes before capture. From a comparison between the experimental barrier distributions and the evaporation residue cross sections for Sg (Z=106), Hs (108), Cn (112), and Lv (116), it is suggested that the hot fusion reactions take advantage of a compact collision, where the projectile approaches along the short axis of a prolately deformed nucleus. A new method is proposed to estimate the optimum incident energy to synthesize unknown superheavy nuclei using the barrier distribution.

A Targeted Genetic Association Study of the Rare Type of Osteomyelitis

Chronic nonbacterial osteomyelitis is a rare bone disorder that can be found in the jaw. It is often associated with systemic conditions, including autoimmune deficiencies. However, little is known about how the genetic and immunologic background of patients influences the disease. Here, we focus on human leukocyte antigen (HLA), killer cell immunoglobulin-like receptors (KIRs), and their specific combinations that have been difficult to analyze owing to their high diversity. We employed a recently developed technology of simultaneous typing of HLA alleles and KIR haplotype and investigated alleles of the 35 HLA loci and KIR haplotypes composed of centromeric and telomeric motifs in 18 cases and 18 controls for discovery and 472 independent controls for validation. We identified an amino acid substitution of threonine at position 94 of HLA-C in combination with the telomeric KIR genotype of haplotype tA01/tB01 that had significantly higher frequency (>20%) in the case population than in both control populations. Multiple logistic regression analysis based on a dominant model with adjustments for age and sex revealed and validated its statistical significance and high predictive accuracy (C-statistic ≥0.85). Structure-based analysis revealed that the combination of the amino acid change in HLA-C and the telomeric genotype tA01/tB01 could be associated with lower stability of HLA-C. This is the first case-control study of a rare disease that employed the latest sequencing technology enabling simultaneous typing and investigated amino acid polymorphisms at HLA loci in combination with KIR haplotype.

Oral function and vertical jump height among healthy older people in Japan

OBJECTIVE

Vertical jump height and oral function affect the general muscle condition. This study aimed to evaluate the association between vertical jump height and oral function among healthy older individuals.

BASIC RESEARCH DESIGN

Cross-sectional analytic study.

PARTICIPANTS

231 independent older people (mean age, 74.4 ± 5.6 years) who participated in the Kyoto Elders Physical Fitness Measurement Research Project. Individuals with partial or complete edentulousness who did not use a prosthetic device or complained of oral/maxillofacial pain were excluded from the study.

INTERVENTIONS

Grip strength was measured using a Smedley Hand Dynamometer. To measure masticatory performance, the participants were instructed to chew a gummy jelly on their habitual chewing side (left or right) for 20 s. Occlusal force, contact area, and pressure were also assessed.

MAIN OUTCOME MEASURES

The outcome variable was vertical jump height. The predictor variables were physical status (age, body mass index, and grip strength), oral status (number of present teeth and denture use), and oral function (masticatory performance, occlusal force, occlusal contact area, occlusal pressure, and tongue pressure). These relationships were evaluated with univariate analysis, and then multiple regression analysis was performed with age as the covariate for each male and female participant.

RESULTS

Vertical jump height was significantly associated with grip strength in both men and women. Moreover, in women, it was associated with masticatory performance, occlusal force, and occlusal contact area.

CONCLUSIONS

Vertical jump height was closely associated with oral function among healthy older women.

Continuous cell culture monitoring using a compact microplate reader with a silicone optical technology-based spatial filter

Continuous cell monitoring is very important for the maintenance and control of cell multiplication and differentiation. This paper presents a compact microplate reader that is able to continuously measure a 24-well microplate (6 × 4 wells) using the optical absorption measurement method. The 24-channel plate reader consisted of a spatial filter, light emitting diode light source, and color sensors and was similarly sized with the cell culture microwell plates. A spatial filter was previously fabricated by our group using silicone optical technology (SOT). This SOT-based spatial filter has an excellent noise reduction effect. Light reflection at the optical path interface can be absorbed and only forward light can be transmitted; accordingly, a larger S/N ratio than that of conventional optical systems is expected. The fabricated 24-channel plate reader permits real-time cell monitoring during cultivation on the clean bench and in cell culture conditions by incorporating the SOT spatial filter. Using the device, it was possible to continuously evaluate the concentration and pH of reagents in the 24 wells in real time. Moreover, cell activity and protein production were detectable using the device. These results suggest that the newly fabricated device is a promising tool for the evaluation of cell behaviors for cell management.

A Comparison of Laparoscopic Redo Fundoplications for Failed Toupet and Nissen Fundoplications in Children

Purpose:

We compared laparoscopic redo fundoplications performed for failed laparoscopic Toupet fundoplication (LTF) and failed laparoscopic Nissen fundoplications (LNFs).

Methods:

Redo LTF (R-LTF; n = 4) and redo LNF (R-LNF; n = 6) performed between 2007 and 2014 were assessed retrospectively for severity of intraperitoneal adhesions on a scale of 0–3, identification/preservation of the anterior/posterior/hepatic branches of the vagus nerve (VN), complications, and outcome.

Results:

Redos were performed after a mean of 34 months in R-LTF and 32 months in R-LNF (P = ns) indicated for sliding hernia (n = 3; 2 with partial wrap dehiscence) and partial wrap dehiscence (n = 1) in R-LTF and sliding hernia (n = 6; 4 with partial wrap dehiscence) in R-LNF. The mean adhesion severity score was 1.5 in R-LTF and 2.5 in R-LNF (P < 0.05). The mean number of VN branches identified/preserved was 2.0 in R-LTF and 0.8 in R-LNF (P < 0.05). Mean operative times and mean blood loss were similar. Intraoperative complications were accidental local trauma (n = 1 in R-LTF and n = 3 in R-LNF, one requiring conversion to open repair) (P = ns). Gastric outlet obstruction developed in two R-LNF cases; both were managed conservatively. There have been no further recurrences to date.

Conclusion:

Although our series is small, adhesions were less, and identification/preservation of VN was easier during R-LTF.

Experimental validation of laryngotracheal growth and recurrent laryngeal nerve preservation after partial cricotracheal resection in a growing rabbit model

PURPOSE

The aim of this study was to confirm laryngotracheal growth and recurrent laryngeal nerve (RLN) preservation after partial cricotracheal resection (PCTR) in a growing rabbit model by performing the procedure in pediatric animals.

METHODS

Six female Japanese white rabbits, 12 weeks of age, underwent PCTR. The course of the RLN was evaluated during surgery (n = 3). Endoscopic and histologic examinations were performed at 22 weeks of age (n = 6). Four non-operated rabbits, 22 weeks of age, underwent endoscopic and histologic examinations as controls.

RESULTS

The RLN was preserved at the esophageal side and entered the larynx behind the cricothyroid joint after PCTR. Endoscopic examination showed normal vocal cord movements and the large reconstructed subglottis. Histologically, sufficient submucosal vessels and cartilage growth were identified at the reconstructed larynx. The median inside luminal area at the anastomotic site in the PCTR group was 24.8 mm² (range 21.8-29.0 mm²), and that at the cricoid cartilage and trachea in the control group was 23.4 mm² (range 20.0-26.6 mm²) and 25.6 mm² (range 22.9-28.8 mm²), respectively.

CONCLUSION

No interference with laryngotracheal growth was seen, and RLN preservation was confirmed after PCTR. Use of PCTR in the pediatric age group seems appropriate.

Clinical features and risk factors of bile duct perforation associated with pediatric congenital biliary dilatation

PURPOSE

This study aimed to investigate the clinical features and risk factors of bile duct perforation in pediatric congenital biliary dilatation (CBD) patients.

METHODS

CBD patients, whose initial symptom was abdominal pain, were enrolled in this study and were divided into perforated and non-perforated groups. The clinical features of the perforated group were investigated. Moreover, the age at operation, sex, and morphologic features of the extrahepatic bile duct were compared between the groups.

RESULTS

Fifteen cases of bile duct perforation (10.4%) were identified among the 144 CBD patients who had abdominal pain. Majority of bile duct perforation occurred in patients aged < 4 years. The median duration from onset of abdominal pain to bile duct perforation was 6 (4-14) days. Age at onset [< 4 years old; P = 0.02, OR 13.9, (1.663, 115.3)], shape of extrahepatic bile duct [non-cystic type; P = 0.009, OR 8.36, (1.683, 41.5)], and dilatation of the common channel [P = 0.02, OR 13.6, (1.651, 111.5)] were risk factors of bile duct perforation.

CONCLUSIONS

Emergent bile duct drainage might be planned to prevent bile duct perforation if CBD patients have the abovementioned risk factors and experience persistent abdominal pain lasting for a few days from onset.

Preoperative oral care and effect on postoperative complications after major cancer surgery

Background

Improving patients' oral hygiene is an option for preventing postoperative pneumonia that may be caused by aspiration of oral and pharyngeal secretions. Whether preoperative oral care by a dentist can decrease postoperative complications remains controversial. A retrospective cohort study was undertaken to assess the association between preoperative oral care and postoperative complications among patients who underwent major cancer surgery.

Methods

The nationwide administrative claims database in Japan was analysed. Patients were identified who underwent resection of head and neck, oesophageal, gastric, colorectal, lung or liver cancer between May 2012 and December 2015. The primary outcomes were postoperative pneumonia and all-cause mortality within 30 days of surgery. Patient background was adjusted for with inverse probability of treatment weighting using propensity scoring.

Results

Of 509 179 patients studied, 81 632 (16·0 per cent) received preoperative oral care from a dentist. A total of 15 724 patients (3·09 per cent) had postoperative pneumonia and 1734 (0·34 per cent) died within 30 days of surgery. After adjustment for potential confounding factors, preoperative oral care by a dentist was significantly associated with a decrease in postoperative pneumonia (3·28 versus 3·76 per cent; risk difference − 0·48 (95 per cent c.i. −0·64 to−0·32) per cent) and all-cause mortality within 30 days of surgery (0·30 versus 0·42 per cent; risk difference − 0·12 (−0·17 to −0·07) per cent).

Conclusion

Preoperative oral care by a dentist significantly reduced postoperative complications in patients who underwent cancer surgery.

Comparison of laparoscopic Toupet and laparoscopic Nissen fundoplications in neurologically normal children

INTRODUCTION

We compared laparoscopic Toupet fundoplication (LTF) and laparoscopic Nissen fundoplication (LNF) in neurologically normal children.

METHODS

Forty neurologically normal children who were followed up for more than 3 years after LTF (n = 22) or LNF (n = 18) were reviewed retrospectively. LTF and LNF were performed between 2006 and 2012.

RESULTS

There were no significant differences in gender (LTF, 15 male and 7 female patients; LNF:, 12 male and 6 female patients), mean age at surgery (LTF vs LNF: 2.5 vs 2.3 years), mean weight at surgery (LTF vs LNF: 9.6 vs 8.9 kg), preoperative symptoms, preoperative pH monitoring (pH <4) (LTF vs LNF: 26.7% vs 21.8%), mean operative time (LTF vs LNF: 117 vs 126 min), postoperative recommencement of enteral feeding (LTF vs LNF: 3.7 vs 3.8 days), or duration of hospitalization (LTF vs LNF: 5.5 vs 6.3 days). Intraoperative complications were esophageal trauma (LTF; n = 1; 4.5%) and liver trauma (LNF; n = 1; 5.6%) (P = 0.70). Post-LTF complications were wrap stenosis (n = 1; 4.5%), and post-LNF complications were wrap stenosis (n = 1; 5.5%) and gastric outlet obstruction (n = 1; 5.5%) (P = 0.43); all were managed conservatively. No case required conversion to open repair. There was no recurrence after LTF, but there were three cases (16.7%) after LNF (P = 0.08). Reoperation was performed at 4, 11, and 13 months, respectively.

CONCLUSION

Despite LTF and LNF appearing to be equally effective, three LNF cases required reoperation.

First Direct Mass Measurements of Nuclides around Z=100 with a Multireflection Time-of-Flight Mass Spectrograph

The masses of ^{246}Es, ^{251}Fm, and the transfermium nuclei ^{249-252}Md and ^{254}No, produced by hot- and cold-fusion reactions, in the vicinity of the deformed N=152 neutron shell closure, have been directly measured using a multireflection time-of-flight mass spectrograph. The masses of ^{246}Es and ^{249,250,252}Md were measured for the first time. Using the masses of ^{249,250}Md as anchor points for α decay chains, the masses of heavier nuclei, up to ^{261}Bh and ^{266}Mt, were determined. These new masses were compared with theoretical global mass models and demonstrated to be in good agreement with macroscopic-microscopic models in this region. The empirical shell gap parameter δ_{2n} derived from three isotopic masses was updated with the new masses and corroborates the existence of the deformed N=152 neutron shell closure for Md and Lr.

A case of biliary atresia with pancreaticobiliary maljunction

Background

The pathogenesis of biliary atresia (BA) is still unknown. There are several reports on the etiology of BA, including pancreaticobiliary maljunction (PBM). We experienced a case of Kasai type IIIa BA with PBM, in which we found elevation of pancreatic enzymes in the gallbladder. We evaluated whether PBM is related to the pathogenesis of BA based on our findings.

Case presentation

The patient was born at 40 weeks of gestation. His body weight at birth was 2850 g. At the age of 4 days, he had an acholic stool and was referred to our hospital. Abdominal ultrasonography showed that triangular cord sign was negative. The gallbladder was isolated with a diameter of 19 mm, and it contracted in response to oral feeding. His ultrasonographic findings were atypical for BA, but his jaundice did not improve. Therefore, we performed an operation at the age of 56 days. Intraoperative cholangiography showed a common bile duct and pancreatic duct and a common channel patent, while the common hepatic duct or intrahepatic duct was not visualized. Bile in the gallbladder contained colorless fluid, which showed elevated lipase level (34,100 IU/L). We performed Kasai portoenterostomy under the diagnosis of Kasai type IIIa BA with PBM. The patient’s postoperative course was uneventful, and he was discharged on day 30 after the operation. Histopathological evaluation showed that the lumens of the common bile duct and cystic duct were patent. However, the common hepatic duct was closed, and only bile ductules with diameters of less than 50 μm were isolated. Infiltration of lymphocytes was detected in the porta hepatis. No apparent inflammation was observed around the cystic duct, which was constantly exposed to pancreatic juice because of reflux through PBM.

Conclusions

Reflux of pancreatic juice through PBM might not be an etiological factor for BA, but might be associated with patency of the common and cystic bile ducts in Kasai type IIIa BA.

Comparison of laparoscopic hepaticojejunostomy and open hepaticojejunostomy. Can stenosis of the hilar hepatic duct affect postoperative outcome?

INTRODUCTION

The aim of this study was to compare laparoscopic hepaticojejunostomy (LHJ) and open hepaticojejunostomy (OHJ) for choledochal cyst associated with hilar hepatic duct stenosis (HHDS).

METHODS

Data collection was prospective for LHJ cases from 2009 and retrospective for OHJ cases from 2003 to 2008. Data were compared with respect to HHDS. HHDS was incised longitudinally as required during hilar hepatic ductoplasty.

RESULTS

Fifty-eight subjects were studied (LHJ: n = 27, 4 boys, 23 girls; OHJ: n = 31; 6 boys, 25 girls). HHDS was present in 10 LHJ cases and 10 OHJ cases. Todani classification of choledochal cyst in LHJ patients was type 1A (n = 16) and type 4A (n = 11), and in OHJ patients, it was type 1A (n = 19) and type 4A (n = 12). There were significant differences between LHJ and OHJ with regard to mean operative time (386 vs 341 min), mean blood loss (5.9 vs 18.4 mL), recommencement of enteral feeding (3.9 vs 6.4 days), and hospital stay (11.7 vs 15.5 days) (all P < 0.05). Hepatic ductoplasty was performed in 23 LHJ patients and in 21 OHJ patients. There were no intraoperative complications and no conversions to OHJ. There were no significant differences between LHJ and OHJ, regardless of the presence of HHDS, for postoperative complications, which included minor bile leakage, anastomotic stricture, and intestinal obstruction.

CONCLUSION

LHJ is as effective as OHJ for the treatment of choledochal cysts irrespective of the presence of HHDS and the need for hepatic ductoplasty.

Impact of renal transplantation on glucose tolerance in Japanese recipients with impaired glucose tolerance

AIMS

To investigate changes in glucose tolerance, insulin secretion and insulin sensitivity in Japanese recipients before and 1 year after renal transplantation.

METHODS

We conducted a study of Japanese recipients without diabetes who underwent renal transplantation at Hokkaido University Hospital. A 75-g oral glucose tolerance test was performed before and 1 year after renal transplantation in these recipients. Insulin sensitivity was estimated using the Matsuda index and homeostasis model assessment of insulin resistance (HOMA-IR). Insulin secretion was evaluated based on the insulin secretion sensitivity index-2 (ISSI-2).

RESULTS

Of the 62 renal transplant recipients, 31 were diagnosed as having impaired glucose tolerance before transplantation. Among these 31 recipients, after 1 year, four had developed new-onset diabetes after transplantation, and nine had impaired glucose tolerance. Unexpectedly, 18 changed from impaired to normal glucose tolerance. When these recipients with impaired glucose tolerance were classified into a non-amelioration group and an amelioration group, the ISSI-2 was significantly reduced, with no significant changes in the Matsuda index or HOMA-IR, in the non-amelioration group 1 year after renal transplantation. By contrast, ISSI-2 and Matsuda index values were significantly increased, with no significant changes in HOMA-IR values in the amelioration group.

CONCLUSIONS

More than half of Japanese renal transplant recipients with impaired glucose tolerance had normal glucose tolerance 1 year after renal transplantation. These results suggest that an increase in insulin secretion and whole insulin sensitivity was associated with improvement in glucose tolerance in these recipients.