Nagoya Journal of Medical Science

Now we are facing to aging society. We aimed to determine the long-term outcomes receiving adjuvant chemotherapy among elderly patients with stage III colorectal cancer. Elderly patients (≧65 years, n=91) diagnosed as stage III colorectal cancer and received adjuvant chemotherapy were retrieved from the database and classified into two groups according to whether the patient received monotherapy (n=65) or doublet therapy(n=26). Recurrence-free survival and overall survival were compared between the groups. To balance the essential variables, we conducted propensity score matching. After one-to-one propensity score matching, each group consisted of 22 patients. No significant difference was detected by comprehensive geriatric assessment 7. Overall survival was significantly longer in the monotherapy group. Adverse events occurred more frequently in the doublet therapy group. Monotherapy may improve the long-term outcome of elderly patients while the adverse events were less frequent.

Type 2 diabetes mellitus (T2DM) may be independently associated with testosterone deficiency syndrome (TDS). Both conditions are linked with reduced quality of life and cardiovascular comorbidities. The magnitude of TDS among T2DM men and its predictors has still not been well established in Malaysia. This study aimed to determine the prevalence of TDS and its predictors among men with T2DM attending a government health clinic in Kuching, Sarawak. TDS severity and level of serum total testosterone were also explored. A cross-sectional study was conducted involving 360 respondents. Aging Males Symptoms Scale (AMS) score > 26 and serum total testosterone ≤ 12 nmol/L were used to diagnose TDS. The prevalence of TDS in current study was 19.7%. Multivariate analysis showed that determinants for TDS included age (Adjusted OR 1.061: 95% CI 1.020; 1.103), Iban ethnicity (Adjusted OR 2.469: 95% CI 1.154; 5.283) and a waist circumference equal or greater than 90 cm (Adjusted OR 3.655: 95% CI 1.472; 9.081). However, there was no significant association between TDS and the level of serum total testosterone (p = 0.581). We concluded that the prevalence of TDS in this study was relatively low. The severity of this condition may not be influenced by testosterone level. Physicians might consider a diagnosis of TDS if elder diabetic men with abdominal obesity present to primary care clinics with clinical features of hypogonadism. Health care providers also might consider lowering their threshold to screen for TDS among Iban men with T2DM.

Platelet Mapping can measure both the degree of platelet inhibition and fibrinogen activation, was not originally designed to measure fibrinogen concentration. Traditional laboratory fibrinogen concentration testing requires around 60 minutes; however, fibrinogen activation only takes 10 minutes, and is indicated as maximum amplitude of activator f. If Platelet Mapping can predict fibrinogen concentration during cardiopulmonary bypass, this could facilitate rapid hemostasis management. The aim of this study was to verify whether fibrinogen concentration could be predicted using Platelet Mapping results. Thus, a pilot study was conducted to evaluate this concept during cardiopulmonary bypass. This prospective, observational pilot study investigated 15- to 90-year-old patients who underwent cardiac or aortic surgery from August 2019 to September 2019. Twenty-one patients enrolled in this study, and 43 blood samples were obtained for both fibrinogen activation measurements using Platelet Mapping and traditional laboratory-based tests, respectively. Correlations between results were analyzed using linear regression and the receiver operat-ing characteristic curve. Correlation by Pearson’s correlation analysis indicates a significant relationship (correlation coefficient of r = 0.91), and a receiver operating characteristic curve indicated that sensitivity, specificity, and receiver operating characteristic area were 100% (95% confidence interval, 75.3–100%), 93.8% (79.2–99.2%), and 0.995 (0.984–1.00), respectively. Our results indicate a strong correlation between fibrinogen activation and serum fibrinogen concentration. The maximum amplitude of activator f can estimate low fibrinogen concentration faster than traditional methods; this method quickly provides important information for anesthesia and hemostatic management in cardiac surgery.

Solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare tumor derived from mesenchymal tissue. Although standard chemotherapy for SHT/HPC has not been established, temozolomide plus bevacizumab (TMZ+Bev) therapy for SFT/HPC has been reported. The effectiveness and safety of TMZ+Bev (temo-zolomide 150 mg/m² orally on days 1–7 and days 15–21 and bevacizumab 5 mg/kg intravenously on day 8 and day 22 on a 28-day cycle), which was administered from December 2013 until April 2019 to four patients with SFT/HPC, were retrospectively analyzed. Four patients with SFT/HPC received TMZ+Bev. The age of the patients ranged from 41 to 75 years. Two were male, and the primary tumor sites were the meninges in three patients and the pleura in one. One achieved partial response; the others, stable disease (SD). The progression-free survival time ranged from 9.4 to 29.6 months according to RECIST v1.1. One patient died 59 months after using TMZ+Bev, and the others survived for 17 to 64 months. All patients experienced Grade 3 or higher lymphopenia, and three had Grade 3 or higher leukopenia and neutropenia. One patient subsequently received doxorubicin; another, pazopanib. TMZ+Bev therapy for SFT/HPC is safe and effective for maintaining long-term SD.

The present study evaluated our modified technique for placing a valve one size larger for Biological Bentall (Bio-Bentall) with a stented valve using a double sawing ring technique with a comparison to clas-sical Bio-Bentall with a stent-less valve. Between December 2001 and July 2017, 44 patients (10 stent-less and 34 stented) with Bio-Bentall were included in this study. The early and mid-term surgical outcomes and re-operation free rates, including the structural valve deterioration (SVD) rate, were investigated. The mean follow-up duration was 69 months. There were two in-hospital mortalities in the stent-less group and one in the stented group, showing no significant difference. The survival at 1, 5 and 10 years was 80%, 50% and 30% in the stent-less group and 85%, 77% and 71% in the stented group, respectively, with a significant difference. There were no cases of SVD occurrence in either group. Freedom from re-operation at 1, 5 and 10 years was 100% at all points in the stent-less group and 100%, 96% and 96% in the stented group, respectively, without significance. The mean pressure gradient through the aortic valve according to the most recent echocardiogram was 8.1 mmHg in the stent-less group and 15.8 mmHg in the stented group, without significance. Our modified technique for Bio-Bentall showed a feasible short- and mid-term survival compared to classical stent-less Bio-Bentall. Both techniques had a good outcome concerning SVD occurrence and the re-operation-free rate with a low-pressure gradient in the aortic position.

Paraplegia is one of the most devastating complications during extensive aortic arch repair. We retrospectively analyzed our results by comparing primary repair using the frozen elephant trunk technique (FET) and the classical elephant trunk technique (CET) followed by second-stage thoracic endovascular aortic repair (TEVAR), which has been performed since 2009.
Between March 1997 and September 2015, 91 patients (the mean age: 70 ± 8.6 years old, 73 men and 18 women) underwent total aortic arch replacement with either the FET (54 cases) or CET (37 cases). The CET was followed by second-stage TEVAR with a median duration of 36 days. The number of in-hospital deaths was 2 (3.7%) in FET and none in CET. The overall survival was 73% in FET and 83% in CET at 5 years with no significant difference (p=0.73). Aortic events occurred in 12 cases (22%) in FET and 3 (8%) in CET. The rate of freedom from aortic events was 77% in FET and 91% in CET at 5 years with no significant difference (p=0.45). Five neurologic events (9%) occurred after the FET, and 3 events (8%) occurred after the CET (p=0.85). No patients in the CET group experienced paraplegia, while the FET group showed a relatively high paraplegia rate (17%, p=0.014).The FET with primary repair for extensive aortic arch repair had an acceptable hospital mortality rate and aortic events but was associated with a high incidence of paraplegia. The CET followed by second-stage TEVAR achieved better early results with a low risk of paraplegia and may produce a favorable mid-term surgical outcome for extensive aortic arch repair.

Blood pressure changes around cement insertion during total hip arthroplasty have been investigated; however, there is little agreement regarding whether a similar phenomenon occurs during hemiarthroplasty in the elderly under spinal anaesthesia. Therefore, our objective was to examine blood pressure around cement insertion during hemiarthroplasty in the elderly. For this retrospective, single-centre, case series study, we identified 430 hips of patients aged >65 years who underwent cemented hemiarthroplasty under spinal anaesthesia from January 2010 to August 2018. The maximum regulation ratio (MRR) was used to express changes in blood pressure immediately after cement insertion and was calculated as follows: the greatest difference (positive or negative) during 5 min after cement insertion into the bone canal divided by systolic blood pressure just before cement insertion. The timings of vasopressor administration and blood transfusion were recorded. The median MRR was compared for each American Society of Anesthesiolo-gists (ASA) classification. The mean MRR was 4.0% (SD:10.4; range −26 to 83). MRR of patients with a >10% increase in blood pressure was significantly less than that of patients with a <10% change in blood pressure. Vasopressor was used in three patients 10 min after cement insertion into the bone canal. There was no significant difference between MRR groups and ASA classification (p = 0.182, respectively). MRR was not significantly different for each ASA classification. However, few cases showed a reduction in blood pressure immediately after cement insertion, regardless of ASA classification.

We investigated the impact of prior anticancer treatments such as chemotherapy and radiotherapy on subsequent infertility treatment in cancer survivors who consulted our male infertility division. Of 1,525 male infertility patients who consulted our division between 2008 and 2018, 56 (3.7%) were cancer survivors. Of these, 32 received anticancer treatment (group A) and 24 were treated with surgery alone or were seen before anticancer treatment (group B). Semen analysis revealed that azoospermia in 26 subjects (81.3%) and 14 (58.3%) in groups A and B respectively. Ejaculatory dysfunction was observed 1 in group A and in 2 group B subjects. Sperm cryopreservation before anticancer treatment was performed 4 subjects. Sperm retrieval surgery for intracytoplasmic sperm injection (ICSI) was performed in 13 cases in group A and 10 in group B. Motile sperm were recovered in 7 subjects and in 8 subjects in group A and B respectively. Overall pregnancies and deliveries with ICSI were achieved for 7 subjects (21.9%) in group A, and 9 (37.5%) in group B. Successful sperm retrieval may not be affected by prior anticancer treatment as shown in this study. However, some patients abandoned infertility treatment due to the cost of testing and sperm retrieval surgery. Support for the cost of infertility treatment in cancer survivors is necessary.

This study aimed to assess the prevalence and patterns of tobacco and alcohol use and the associations with socio-demographic variables among presumptive TB patients.
A cross-sectional study was conducted among 397 presumptive TB patients in a tertiary hospital in Myanmar. Global Adult Tobacco Survey (GATS) questionnaire and AUDIT-C were used to measure daily tobacco use (single, any or dual use of smoked and smokeless tobacco) and harmful alcohol use, respectively. Multiple and multinomial logistic regression were used to examine the associations with socio-demographic factors.
The prevalence of daily use of dual tobacco and any tobacco was 28.2% and 65.7%, respectively. Harmful alcohol use was also high (44.8%). While single use of daily tobacco and harmful alcohol was 28.2% and 7.3%, respectively, concurrent tobacco and alcohol use was 37.5%. While being male and having low education were associated with tobacco use, concurrent tobacco and harmful alcohol use were associated with male gender, low education, and occupation with the government or a company.
Due to the high prevalence of tobacco and alcohol misuse, identifying those at risk of tobacco and alcohol misuse and providing integrated care services in a health facility should be considered as a joint activity in national TB and tobacco control programmes.

Communication errors are the most important cause of adverse events in healthcare. The current study aimed to improve hospital-wide employee teamwork and reduce adverse medical events for patients arising from miscommunication. In our hospital, when patient safety incidents and accidents occur, staff from various occupations submit incident reports to the Department of Patient Safety via an electronic reporting system; over 11,000 cases are reported each year. We surveyed the incident reports submitted in our institution from 2016 to 2018. All incidents related to miscommunication were identified, and relevant information was collected from the original electronic incident reports. Incident severity classification is commonly divided into near-miss or adverse events. We extracted only the required incident information items for this study, and processed information concerning individuals (e.g., reporters and target patients) anonymously. This study was approved by the Institutional Review Board of the study hospital. The authors declare no conflicts of interest associated with this study. Team training for all employees reduced adverse events for patients. The coefficient of determination (R squared value) was –0.32. This suggests our approach may be slightly but significantly effective for developing the fundamental strengths of the medical team. Quality improvement is continuous, and seamless efforts to improve the effectiveness of medical teams at our hospital will continue.

Estrogen has an important role in regulating glucose homeostasis, and existing evidence indicates that it might be involved in the development of hyperglycemia in pregnancy. It mediates its effect through estrogen receptors including the nuclear receptor ERβ encoded by ESR2. The association between the ESR2 polymorphism rs1256031 and GDM susceptibility has not been investigated yet. This study aimed to evaluate the relationship between rs1256031 and GDM risk in Chinese population. A total of 241 GDM patients and 139 healthy pregnant women were recruited for this study. The rs1256031 genotype was examined by time-of-flight mass spectrometry and the association between rs1256031 and GDM susceptibility was assessed by binary logistic regression in three different genetic models. The polymorphism rs1256031 was not associated with GDM susceptibility in additive [OR (95% CI) = 0.871 (0.453,1.675); P = 0.680], dominant [OR (95% CI) = 0.908 (0.495,1.665); P = 0.755] or recessive [OR (95% CI) = 0.912 (0.591,1.408); P = 0.677] models after adjusting for confounding factors. We observed no association between the polymorphism rs1256031 in the ESR2 gene and GDM susceptibility in Chinese pregnant women.

The World Health Organization (WHO) defines the postnatal period as the first six weeks (42 days) after delivery and recommends four postnatal care (PNC) visits for women giving birth to a child to enable early detection and treatment of complications. However, a low utilization of PNC visits by Afghan women has contributed to a relatively high maternal mortality in Afghanistan. This study aimed to identify factors influencing the utilization of PNC visits among Afghan women by sampling nationally representative data from Afghanistan Demographic and Health Survey (AfDHS), 2015. The logistic model was used to measure the adjusted odds of utilizing PNC services among women, with a 95% confidence interval (95% CI) and a p-value of <0.05 for statistical significance. The study found that the utilization of PNC visits in Afghanistan is low; among 8,581 women (44%) who utilized PNC visits and 10,924 women (56%) who didn’t, the women’s age, place of residence, parity, education, occupation, number of antenatal care (ANC) visits, place of delivery, exposure to public media, the woman’s role in decision making and needing a permission to seek healthcare were found to be associated with the level of utilization of PNC visits. Based on the study results, health promotion interventions are recommended to increase the utilization of PNC visits.

The standard chemotherapy regimen for unresectable or recurrent biliary tract cancer is gemcitabine combined with cisplatin (GC). To evaluate the effectiveness and safety of chemotherapy in patients with unresectable or recurrent biliary tract cancer in the real world, we retrospectively analyzed the clinical courses of patients who underwent chemotherapy with GC from January 2015 to November 2019. Forty-eight patients underwent the GC regimen. One patient (2.1%) achieved a complete response, seven patients (14.6%) achieved a partial response, 26 patients (54.2) achieved stable disease, 11 patients (22.9%) achieved progressive disease, and 3 patients (6.3%) were not evaluable. The overall response rate was 16.7%. The median overall survival was 14.2 months (95% CI: 13.8–14.6), and the median progression-free survival was 7.7 months (95% CI: 4.2–11.2). Thirty-nine patients (81.3%) experienced grade 3 or higher severe adverse events as follows: 54.2% experienced neutropenia, 20.8% experienced anemia, 12.5% experienced thrombocytopenia and 20.8% experienced biliary tract infection. As a second-line chemotherapy, S-1 was used in seventeen patients, and stable disease was achieved in three patients (17.6%). The GC regimen for biliary tract cancer is effective and safe for unresectable or recurrent biliary tract cancer in routine clinical practice.

Many studies have examined the impression made on patients by physicians’ attire. Regardless of practice location, many patients express most confidence in physicians who wear white coats. The number of physicians in Japan who choose not to wear white coats in practice has been increasing, particularly in primary care settings. However, very few studies have examined physician preference for attire. To clarify Japanese general practitioners’ preference for attire by practice setting, we conducted a survey of physician preferences and reasons for attire selection. Subjects were 794 general practitioners certified by the Japan Primary Care Association and recruited from a mailing list. We conducted a web-based questionnaire survey. Physicians were asked to choose one of four different dress styles (semi-formal, white coat, scrubs, and casual) for different practice settings and state the reasons for selection. The response rate was 19.3% (n = 153; men 112). Most subjects chose white coats as usual attire for hospital practice (52%), mainly because of custom and professionalism. In contrast, most subjects chose non-white coats for clinics (59%) and home care (hospital-provided, 58%; clinic-provided, 71%). More subjects chose casual dress for clinic and home care practice, mainly to appear empathic. Most subjects chose white coats as the most appropriate hospital attire (54%), mainly because of patient perceptions of this attire being professional. Most subjects considered non-white coat attire more appropriate for clinic and home care practice. The findings indicate that general practitioners choose their clothes depending on practice location.

In this retrospective cohort study, we evaluated the incidence of vascular events from carotid artery atherosclerosis after radiotherapy indication for laryngeal and hypopharyngeal cancer. From January 2007 to December 2016, we investigated 111 laryngeal/hypopharyngeal cancer patients who underwent curative radiotherapy and were followed up for ≥1 year (median follow-up duration, 60 months). We evaluated the incidence of vascular events from carotid artery atherosclerosis, defined as a transient ischemic attack or an atherothrombotic cerebral infarction, or from undergoing treatment such as carotid artery stenting for carotid artery stenosis. The median radiation dose was 66 Gy (range, 60–74); 48 patients (43.2%) received concurrent chemotherapy. The 5-year overall survival was 86.2%. Six patients required treatment for carotid artery disease. Carotid stenting was performed in three patients with carotid artery stenosis; three patients developed atherosclerotic cerebral infarction and received medical treatment, with a median of 51.7 months (range, 0.3–78.3) after radiotherapy initiation. The vascular event occurrence rate was 5.4% within 5 years and 10.7% within 8 years. In the univariate analysis, dyslipidemia, diabetes mellitus, and carotid calcification were significant factors for event occurrence. Because three out of six cases occurred out of the irradiated field, no carotid artery or carotid bulb dosimetric parameters showed significant cor-relation. As laryngeal/hypopharyngeal cancer patients, particularly with complications including dyslipidemia and diabetes mellitus, are at a high risk of carotid artery stenosis after radiotherapy, long-term carotid artery evaluation is necessary. Early intervention by stroke specialists can reduce the risk of fatal cerebral infarction.

Snake-bite is a well-known but fairly ignored medical problem in India. Lack of precise first aid knowledge for snake-bite is a substantial reason for its severe fatality in human beings. The present study is comprised of a pilot survey that assesses and evaluates the knowledge of people of different occupations (teachers, students, farmers, medical residents, and miscellaneous) about snakes and snake-bite management. The pilot survey was conducted through a well-structured open-ended questionnaire about experiences with snakes and snake-bites and first aid measures for accidental snake-bites. Proper knowledge of snakes and snake-bite management was either diminutive or absent in the majority of the subjects, especially amongst teachers. Even the medical professionals were not well acquainted with knowledge about snakes and snake-bite management. Only 13% knew about ‘big four’, 18% knew ‘dry bite’, and 21% of subjects knew about anti-snake venom (ASV) used in India. 39% of subjects knew about the whereabouts of traditional healer. Only 12% of subjects, mostly medical residents, knew of any bedside test for diagnosis of snake-bite, and 11% of respondents also knew of LD₅₀ of Indian cobra. A well-timed first aid treatment is always decisive in the management of life-threatening snake-bite cases but the present survey has found that most of the study groups had inadequate and little misleading fundamental knowledge comprising regional snakes, first aid measures for accidental snake-bite, and welfare schemes for snake-bite victims. Therefore, the present study proposes to conduct more such appraisals and strengthening of education curricula on snake-bite that would surely inculcate an adequate level of primary skill in ignorant societies.

Myocardial calcification secondary to acute myocarditis is a rare but possibly life-threatening complica-tion.
We report a 43-year-old woman with minimal change nephrotic syndrome who developed sepsis caused by Escherichia coli. We simultaneously detected the complication of acute myocarditis in the patient.
Although echocardiography showed hypokinesis of the apical segment when acute myocarditis was diagnosed, no sign of myocardial calcification was observed.
After two weeks, a CT showed myocardial calcification in the same area. Although myocardial calcifica-tion was still observed 12 months later, the patient’s cardiac function had improved.

Quantitative Fluorescent – Polymerase Chain Reaction (QF-PCR) is a rapid prenatal diagnosis test for 21, 18, 13 and sex chromosomal aneuploidy detection. However, it could not detect partial trisomy or partial monosomy of those chromosomes. Here, we report a 19-month-old Vietnamese female with a 9.9 Mb pure deletion of chromosome 18 at 18p11.32–11.22 confirmed by next generation sequencing. The patient was short statured with facial dysmorphic features as well as motor skill and speech delays. First trimester screening showed high risk of trisomy 21 with only increased nuchal translucency (NT 3.9 mm) by ultrasound as an indication. Prenatal diagnosis by QF-PCR from amniotic DNA revealed normal disomy. Noticeably, two short tandem repeat (STR) markers D18S391 and D18S976 located on 18p exhibited uninformative patterns (one peak). Thus, our case suggested that the combination of both D18S391 and D18S976 markers with uninformative patterns in QF-PCR for prenatal diagnosis and increased NT in the first trimester ultrasound may be a significant indication of 18p monosomy.

Herein, we present a case of extramammary Paget’s disease with brain metastasis that was diagnosed pathologically for the first time in Japan. Moreover, invasive extramammary Paget’s disease (with distant metastasis) highly resistant to treatment. Only for brain metastasis, we may control the tumor by surgical resection and stereotactic radiosurgery (SRT) for the treatment of intracranial metastases was assessed.
An 76-year-old man was diagnosed with extramammary Paget’s disease of the vulva at nearby hospital. Surgical resection and sentinel lymph node dissection were then performed, and the patient received che-motherapy because multiple lymph node metastases were suspected. The patient’s response to chemotherapy was poor, and he was in the state of Progressive Disease. He complained of dyslexia and was referred to another hospital when he was 81 years old. Plain magnetic resonance imaging (MRI) was conducted, and two brain tumors in the vicinity of the left cerebellar tent were suspected.
In our hospital, gadolinium contrast-enhanced MRI was performed and showed a tumor in the cerebel-lum (left posterior temporal lobe) and another tumor under the tent (left cerebellar hemisphere). Significant edema was also noted. Based on these findings, the intracranial lesion was diagnosed as metastatic brain tumor. The pathological diagnosis was brain metastasis from extramammary Paget’s disease. Postoperative intracranial residual disease was treated with stereotactic radiosurgery. MRI showed that the size of the cerebellar lesions decreased, and no recurrence of cerebral lesions was observed. SRT for extracranial lymph node metastases was performed.
Mass reduction and SRT may be the best way to treat brain metastasis from extramammary Paget’s disease.

A 67-year-old man underwent posterior cervical decompression surgery for ossification of the posterior longitudinal ligament (OPLL) with fixation using cervical pedicle screws (CPSs) guided by intraoperative 3D image-based navigation. Intraoperatively, while creating the screw hole using the navigation probe, the virtual trajectory on the intraoperative navigation screen showed a 10-degree angle discrepancy in the axial plane depending on whether a probing force was or was not applied for making the hole. This was potentially caused by vertebra rotation and a bent probe. Consequently, the CPSs were placed more laterally than the ideal trajectory, which resulted in <2 mm lateral perforation to the foramen transversarium. There were no screw insertion-related perioperative complications. Based on this case, we conclude that navigation error during CPS insertion can occur even with intraoperative 3D image-based navigation. The risk of a bowed navigation probe caused by posterior cervical muscle and vertebra rotation should be considered, even with use of a navigation reference frame.

A 62-year-old female patient with systemic lupus erythematosus (SLE) was admitted for cerebral infarction. The magnetic resonance angiography showed focal narrowing of the cerebral arteries that was initially considered as atherosclerosis due to her cardiovascular risk factors. Ten weeks later, she was again admitted for multiple cerebral infarctions. Vessel wall magnetic resonance imaging revealed gadolinium enhancement of the arterial walls of the narrowing lesions, leading to a diagnosis of cerebral arteritis. Based on a literature review, cerebral medium-sized arteritis in SLE likely progresses insidiously during the active phase of SLE, which may later result in occlusion irrespective of disease activity.