Nagoya Journal of Medical Science

International guidelines suggested that overweight and underweight are risk factors for frailty. However, body composition, which directly affects body weight, was not mentioned as a risk factor. We aimed to investigate whether the body composition, including muscle, fat, bone, and body water, is a risk factor for frailty. MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Scopus were searched up to June 03, 2022. We included cohort studies or observational studies using a cross-sectional design that reported an association between body composition and frailty. Two reviewers assessed the quality of the included cohort studies. Furthermore, we examined whether body composition as a risk factor for frailty varies depending on the participant’s place of residence. Of the 3871 retrieved studies, 77 were ultimately included, 7 of which were cohort studies. The risk-of-bias evaluation in each cohort study showed that all studies had at least one concern. Low lean mass, waist circumference-defined abdominal obesity, and bone mineral density were significantly associated with frailty in the cohort studies. The results of bone mineral density were conflicted in the cross-sectional studies. Considering the participants’ place of residence, a significant association between lower-extremity muscle mass and frailty was demonstrated, particularly among Asian residents. Low lean mass and abdominal obesity were likely risk factors for frailty. These results could be useful for developing frailty prevention strategies and could have a positive impact on individual health management. Further, future studies are needed because body composition affecting frailty may differ by race.

Distinguishing recurrent cholangiocarcinoma lesions from postoperative fibrosis or biliojejunostomy lesions using contrast-enhanced computed tomography (CECT) alone is challenging. This study examined the value of adding diffusion-weighted magnetic resonance imaging (DWI) to CECT for the detection of cholangiocarcinoma recurrence. This single-institution retrospective analysis included 33 patients who underwent cholangiocarcinoma resection between January 2016 and December 2020. Of the patients, 20 were in the recurrence group and 13 were in the non-recurrence group. Two observers independently reviewed the CECT images and subsequently reviewed the combined CECT and DWI images (b-value, 1000 s/mm²), with each image reviewed twice. The diagnostic performance was evaluated using receiver operating characteristic (ROC) curve analysis. Kappa statistics were used to evaluate agreement. The diagnostic performance (area under the ROC curve [AUC]) of both observers improved after the addition of DWI; the AUC improved from 0.614 to 0.918 (P = 0.003) in the first session and from 0.820 to 0.928 (P = 0.20) in the second session for Observer A, whereas it improved from 0.566 to 0.858 (P < 0.001) in the first session and from 0.753 to 0.930 (P = 0.02) in the second session for Observer B. The intraobserver and interobserver agreements improved after the addition of DWI; the kappa value improved from 0.586 to 0.656 for Observer A, from 0.371 to 0.838 for Observer B, from 0.308 to 0.766 in the first session, and from 0.464 to 0.620 in the second session. Adding DWI to CECT improves the detection of cholangiocarcinoma recurrence compared to CECT alone.

Catheter ablation is the first-line treatment for atrial fibrillation. Although the efficacy and safety of this procedure have been reported in older patients, they might diminish with age. Therefore, this study aimed to determine the safety and effectiveness of atrial fibrillation ablation in patients aged ≥80 years. We retrospectively analyzed the features of the catheter ablation and the subsequent clinical course and outcomes of 100 patients with atrial fibrillation aged ≥80 years who underwent ablation between July 2019 and December 2021 at Tosei General Hospital, Seto, Aichi, Japan. The average duration of atrial fibrillation was 6.0 ± 9.5 months, and 83% of the patients were symptomatic. Approximately 30% of patients developed heart failure, with 15% requiring hospitalization within one year before ablation. After ablation, 93% of patients were atrial fibrillation-free, and none required postoperative hospitalization due to heart failure. However, several complications have been observed, including cardiac tamponade, hematoma at the access site, and postoperative bradycardia. Notably, an enlarged left atrial diameter before ablation is a predictor of complications. In patients aged ≥80 years, atrial fibrillation ablation therapy demonstrated a high non-recurrence rate and may alter the progression of heart failure. Although the incidence of complications was relatively low, caution should be exercised when older patients with enlarged left atrial diameters undergo atrial fibrillation ablation.

Heparinized saline is used to prevent catheter obstruction; however, it is associated with concerns regarding the incidence of heparin-induced thrombocytopenia and the accuracy of the blood test results. This study compared the impact of saline with and without heparin on central venous catheter occlusion rates in post-surgical intensive care unit patients using a prospective, double-blinded, randomized, controlled design. Patients aged 20–90 years planned to experience central venous catheter insertion and postoperative intensive care unit admission were enrolled and were randomly assigned to either the heparin group (administered normal saline with heparin) or the control group (administered normal saline alone), based on a 1:1 ratio. Nurses blinded to patient allocation performed the occlusion assessment (every 24 h). The Kaplan–Meier curve was used to assess the time to occlusion or removal of each catheter. Central venous catheter insertion results of 136 patients showed no significant variation in occlusion rates between the heparin and control groups within the first 3 days. There was no significant difference between normal saline with and without heparin in preventing central venous occlusion in the intensive care unit up to 3 days post-surgery. The results of this study suggest that it is not necessary to use normal saline with heparin in the management of central venous catheter occlusion, at least when moving from the operating room to the intensive care unit.

Locomotive syndrome is a decline in mobility and is believed to occur before the occurrence of frailty and sarcopenia; therefore, early detection of risk factors is important. However, systematic reviews have not been conducted. A systematic review of observational studies was performed to identify risk factors for the development or progression of locomotive syndrome. We searched the electronic databases of MEDLINE, Scopus, Web of Science, Ichushi Web (in Japanese), and Cumulative Index to Nursing and Allied Health Literature. Studies that used the development or progression of locomotive syndrome as an outcome and were written in English or Japanese were included. However, studies with nonadult participants and review articles were excluded. The quality of the eligible studies was evaluated using the Cochrane risk-of-bias instrument. This study included 79 observational studies (8 cohort and 71 cross-sectional studies). A meta-analysis was not performed. All studies were conducted in Japan. The eight cohort studies included 2,343 participants aged 57.0–79.3 years upon study initiation. The risk factors for developing locomotive syndrome were objectively assessed by parameters of motor function and muscle strength, such as short one-leg standing time and weak grip strength. The progression of locomotive syndrome was associated with the preoperative risk stage of locomotive syndrome and postoperative surgical failure syndrome. Locomotive syndrome can be detected through the regular assessment of motor function and muscle strength. To prevent locomotive syndrome in middle-aged and older people, an examination by an expert is necessary.

Since the COVID-19 pandemic, it has been found that SARS-CoV-2 antecedent infection can cause multisystem inflammatory syndrome in children. However, the frequency of SARS-CoV-2 antecedent infection in Kawasaki disease (KD) is unknown. The purpose of this study was to investigate the frequency of SARS-CoV-2 infection that preceded the onset of KD. This study is a multi-center observational study. The subjects were patients who were diagnosed with KD at 4 hospitals from April 1, 2020 to August 31, 2022. Serum SARS-CoV-2 IgM and total antibody including IgG levels were measured by the chemiluminescence immunoassay method before and after treatment for KD. A total of 55 patients participated in the study. The first antibody measurement before the initial treatment was performed on a median of 4th days of illness and the second antibody measurement was performed after the initial treatment on a median of 12th days of illness. No patient had a significant increase in SARS-CoV-2 IgM levels in two measurements. Only one patient (1.8%) had elevated total antibodies including IgG, and the patient had a history of COVID-19 6 months before the onset of KD. SARS-CoV-2 antecedent infection before the onset of KD was not observed in this study, and strong association between development of KD and SARS-CoV-2 infection was not suggested.

Although conservative treatment and laparoscopic surgery are becoming increasingly popular for acute appendicitis, emergency open appendectomy is still performed in many situations. The purpose of this study was to examine the surgical outcomes of emergency open appendectomy for acute appendicitis. Between July 2008 and August 2022, 2,268 patients who underwent emergency open appendectomy for acute appendicitis were enrolled in this study. Of these patients, 417 (18.4%) had complicated appendicitis (CA), and 1,851 (81.6%) had uncomplicated appendicitis (UA). Clinical characteristics and both surgical and postoperative outcomes were compared between the groups. The percentage of CA patients increased after 2020, and by age, the proportion was greater for those aged 50 and older. In the CA group, patients were older (55.5 vs 30.0 years, p<0.001) and had more comorbidities (34% vs 12%, p<0.001). Additionally, in the CA group, the operation time was longer (86 vs 55 min, p<0.001), and the rate of postoperative complications was greater (16% vs 3.0%, p<0.001). There was one mortality in the CA group due to postoperative cerebral infarction. The postoperative hospital stay was significantly longer in the CA group (9 vs 5 days, p<0.001). In conclusion, in the CA group, the patients were older and had more comorbidities. Patients who underwent emergency open appendectomy for CA had longer operation times and more complications. This large single-center study provides insights into emergency open appendectomy for acute appendicitis and useful information in terms of comparisons with other treatment modalities, such as laparoscopic appendectomy and elective appendectomy.

Gastric cancer is a common malignancy disease with a poor prognosis. Deficient mismatch repair is a prognostic and predictive marker of response to systemic therapies. However, deficient mismatch repair frequency and the relationship between this status and microscopic characteristics are inconsistent across nations. We aimed to determine the rate of deficient mismatch repair and its association with histopathological features in gastric cancer patients. A cross-sectional study was conducted on 226 gastric cancer patients treated at Hue University of Medicine and Pharmacy Hospital and Hue Central Hospital from June 2020 to January 2024. Mismatch repair protein expression was evaluated using immunohistochemical staining, and any absence of mismatch repair proteins was regarded as deficient mismatch repair. The deficient mismatch repair rate was 12.8%. Deficient mismatch repair appeared to be more frequent in the intestinal subtype of Lauren classification odds ratio (OR) = 4.767 (95% confidence interval [CI], 1.086–20.921; p = 0.039), tubular/papillary adenocarcinoma (OR = 5.25; 95% CI, 1.185–23.251; p = 0.029), mucinous adenocarcinoma (OR = 6.19; 95% CI, 1.113–34.445; p = 0.037), and differentiated type (OR = 3.24; 95% CI, 1.324–7.931; p = 0.01). No statistically significant association was detected with histopathological features according to the Tumor Location-Modified Lauren classification and mucinous secreting morphology. Deficient mismatch repair status was unusual in gastric cancer. The degree of cell differentiation and microscopic characteristics based on the World Health Organization and Lauren classification could all impact the predictive power for microsatellite-instable status.

The number of individuals with age-related mild cognitive impairment and subsequent dementia has inevitably increased with the rise in population aging. It is important to maintain cognitive function or decelerate declines in cognitive function. However, the evidence on lifestyle-based factors associated with this decline is lacking. Here, we investigated modifiable lifestyle-based factors associated with chronological cognitive decline in cognitively healthy adults aged ≥60 years (Mini-Mental State Examination [MMSE] score ≥27). This case-control study enrolled 363 participants who were divided into two groups based on annual declines in MMSE score: 40 cases with an MMSE score decline of ≥0.5 points/year and 323 controls with maintained MMSE scores. Smoking, lower social functioning scores on the 36-Item Short Form Health Survey version 2, higher Pittsburgh Sleep Quality Index (PSQI) global scores, and sleep disorders were significantly associated with a decline in MMSE scores. Multivariate logistic regression analysis revealed higher age, current smoking status, and either higher PSQI global scores or sleep disorders to be independently associated with MMSE score decline. In conclusion, the present study identified aging, smoking, and sleep quality as factors associated with a greater decline in MMSE scores in cognitively healthy individuals. Our findings highlight the potential importance of lifestyle factors in preventing cognitive decline.

The Maze procedure is a well-established technique for treating atrial fibrillation; however, atrial tachyarrhythmias can recur postoperatively. This study analyzed the mechanisms of recurrence in patients who underwent electrophysiological studies and catheter ablation following the Maze procedure. Among 88 patients who underwent treatment with a modified Maze procedure, 42 developed recurrent atrial tachyarrhythmias. Among these, 18 underwent electrophysiological studies and simultaneous transcatheter radiofrequency ablation. The median period between the Maze procedure and catheter ablation was 29 months. Macro-reentrant circuits were identified in 12 patients (67%) with or without atrial fibrillation. Most patients (n = 15, 83%) had more than one conduction gap. The most frequently identified gap was around the left inferior pulmonary vein (n = 10, 56%), followed by the peri-coronary sinus area (n = 8, 44%), and the mitral isthmus area (n = 5, 28%). Catheter ablation targeting these gaps successfully eliminated tachyarrhythmias in 15 (83%) patients. At a follow-up examination 49 months after catheter ablation, 14 patients (78%) had no recurrence of tachyarrhythmia. An electrophysiological study revealed conduction gaps in patients with recurrent atrial tachyarrhythmia after the Maze procedure. Modifications to the Maze procedure should include meticulous ablation around the left inferior pulmonary vein orifice, mitral isthmus, and coronary sinus where conduction gaps frequently occur. In cases of recurrence, catheter ablation targeting the lesion effectively controlled the tachyarrhythmia.

Chronic obstructive pulmonary disease is one of the leading causes of death worldwide and in Japan. This study aimed to detect the location and area of spatial clusters with high chronic obstructive pulmonary disease mortality rates in Japan during 2017–2021. Age-standardized numbers of expected chronic obstructive pulmonary disease deaths by sex and municipality were estimated from publicly available data from 1,895 municipalities in Japan. We performed flexible spatial scan statistics to detect the clusters with significantly high risk of chronic obstructive pulmonary disease death using the expected and observed cumulative mortality. During 2017–2021, the cumulative expected number of chronic obstructive pulmonary disease deaths was 87,450 (72,551 males and 14,899 females). There were 23 significant spatial clusters for males and 14 for females. The 23 clusters were scattered in 251 municipalities of 27 prefectures for males, while the 14 clusters for females were localized in 105 municipalities of 12 prefectures. The primary cluster for both sexes was detected in the Osaka Prefecture (males: log-likelihood ratio [LLR] = 188.23, relative risk [RR] = 1.46, p = 0.001; females: LLR = 106.42, RR = 1.95, p = 0.001). We found 23 significant spatial clusters for males and 14 for females. There were obvious sex differences in the distribution of the clusters. Our findings provide supporting evidence to discuss the prioritized areas in the allocation of health care resources to prevent and control the deaths associated with chronic obstructive pulmonary disease.

Short stature and growth retardation is a common condition in children. Genetic variations are responsible for many cases of short stature of unknown etiology. In particular, pathogenic copy number variants (CNVs) have been found in 10%–16% of children with unexplained short stature. This paper reports on a 5-year-old Japanese girl with both growth retardation and developmental delay associated with a 16p13.11 microduplication. Although the patient’s mother also carries this microduplication, she did not show growth retardation and developmental delay. These cases illustrate the diverse phenotypic manifestations of 16p13.11 microduplication. Consequently, we conducted the literature review of 274 cases associated with this duplication revealed neurological disorders in approximately 70% of cases, 15.3% of these cases were associated with short stature. Diagnosis of 16p13.11 microduplication remains challenging due to its diverse symptomatology and elusive genotype–phenotype correlations. Comprehensive genetic evaluation is crucial for patients presenting with short stature and developmental disorders, underscoring the need for further investigation into the 16p13.11 microduplication to clarify its specific role and implications.

A 9-year-old boy fell off his skateboard, resulting in a supracondylar fracture of his left humerus. The fracture was surgically repaired on the same day using two Kirschner wires inserted from the medial and lateral sides. Following surgery, the patient developed ulnar nerve palsy, prompting reoperation. It was discovered that the ulnar nerve was located anterior to the medial epicondyle and was snagged on the Kirschner wire, causing compression. Despite clear confirmation of the wire entry site, the presence of an unstable ulnar nerve anterior to the medial epicondyle necessitates caution to prevent ulnar nerve injury.

Herein, we present a case of severe immune-related adverse events (irAEs), myocarditis with myositis, and myasthenia gravis overlap syndrome (IM3OS) in a patient receiving an immune checkpoint inhibitor (ICI), as adjuvant therapy after surgery for muscle-invasive bladder cancer. An 80-year-old woman who had undergone a total cystectomy for bladder cancer presented with ptosis, diplopia, and paralysis 18 days after receiving nivolumab, an anti-programmed cell death-1 (PD-1) monoclonal antibody, as adjuvant therapy for the first time. Initial testing revealed positive findings on the ice pack test; elevated troponin, creatine kinase, and aldolase levels; and an abnormal electrocardiogram, suggesting that the patient had developed ICI-related myocarditis, myositis, and myasthenia gravis. Despite treatment with intravenous immunoglobulin (IVIG) and high-dose corticosteroids, her condition worsened, leading to a complete atrioventricular block. After cardiac pacemaker insertion and intensive treatment with repeated high-dose corticosteroids, IVIG, plasma exchange, and tacrolimus, left ventricular function and myositis symptoms improved. However, the patient developed a respiratory infection and renal failure, leading to death on day 99. Although ICIs are considered relatively safe with few side effects, they can cause serious complications and lead to death. In particular, when severe irAEs occur in multiple organs, such as IM3OS, the prognosis is poor. Although IM3OS has no specific diagnostic biomarker, making early detection difficult, clinicians should always pay attention to patient symptoms when using ICI and evaluate other pathologies with IM3OS when conditions such as myositis or myocarditis are suspected. Further research is needed to elucidate the pathophysiology and risk factors of IM3OS.

Kounis syndrome (KS) manifests as an acute coronary syndrome triggered by allergy, hypersensitivity, or anaphylaxis. It is believed that mast cells and histamine can potentially induce acute cardiac events by activating various inflammatory pathways. Here, we present a case of KS triggered by rifampicin administered during empyema drainage in a young male patient with no history of coronary artery disease. To the best of our knowledge, our case is the first report of rifampicin-induced KS documented in the literature. The wide range of etiological factors complicates the diagnosis of KS. Healthcare professionals should consider KS as a potential diagnosis in patients experiencing angina or similar pain alongside suspected allergic reactions.

Intraoperative magnetic resonance imaging (iMRI) plays a crucial role in improving the precision of brain tumor surgeries. However, the use of iMRI can impose certain limitations on intraoperative head positioning. In regular microscopic surgery, head positioning is of utmost importance because an appropriate surgical field is important for the efficacy and safety of surgery. Therefore, in cases where adequate head positioning is difficult, usually, iMRI will not be utilized. Herein, we report an adult case of cerebellar astrocytoma whose tumor extended to the culmen of the cerebellum. Upon surgery via the suboccipital approach, the positional limitations imposed by iMRI led to an insufficient vertex-down position and limited surgical field, which hampered the removal of the upper portion of the tumor. However, this concern could be overcome when used in combination with an endoscope. The potential of iMRI applications is anticipated to be enhanced by overcoming positional limitations through combined endoscopic surgery. The use of multimodality in surgery is an optimal example of how surgical support equipment can also improve surgical outcomes. Here, we report on the new possibilities offered by multimodality.

We sought to explore factors associated with changes in activities of daily living (ADL) in home-based medical care (HBMC). We used data from the Observational Study of Nagoya Elderly with Home Medical Care 2, in which HBMC was provided for physical and/or mental disability. ADL were assessed using the Barthel Index and its mobility and self-care categories. Of 40 eligible participants, half were classified into an ADL decline group. The percentage with a decreased Mini-Nutritional Assessment-Short Form (MNA-SF) score was significantly higher in the ADL decline group. Worsening of MNA-SF was significantly associated with a decline in the mobility category but not in the self-care category. ADL decline was frequently observed and was associated with worsening of nutritional status in HBMC.