VOLUME 84 NUMBER 4 November 2022

Current Issue

ISSN 2186-3326
(Online ISSN)
ISSN 0027-7622
(Print ISSN--v.72no.3/4)


A systematic review assessing the effectiveness of hand therapy programmes in adults with burns using the International Classification of Functioning, Disability and Health framework

Akihito Yoshida, Michiro Yamamoto, Cecilia W. P. Li-Tsang, Katsuyuki Iwatsuki and Hitoshi Hirata
pg(s) 689–704

<Abstract> - < PDF >

This systematic review aimed to confirm the effectiveness of hand therapy programmes using the International Classification of Functioning, Disability and Health framework for each of the three phases of the wound healing process in adults with burns. A systematic review was conducted to determine the efficacy of different hand therapy programmes in the management of burnt hands. Two independent reviewers conducted a literature search using the PubMed and Cumulative Index to Nursing and Allied Health Literature databases for original articles reporting effectiveness of hand therapy programmes for adults with burns. Only randomized and non-randomized controlled trials were selected using the Mixed Methods Appraisal Tool. Demographic and clinical data including medical history, burn depth, and hand therapy programme were extracted. Outcome measures were reviewed based on the International Classification of Functioning, Disability and Health framework for acute, convalescence, and chronic phases of rehabilitation. Sixteen articles and 15 hand therapy programmes were identified, which included studies showing improvements in different parameters in the framework. In the acute and convalescence phases, improvements were found in health condition, body functions and structures, activities, and participation. In the chronic phase, improvements were shown only in body functions and structures. Environmental factors in the framework were not reported for all the phases. This review demonstrated the efficacy of hand therapy programmes in adults with burns in terms of the health condition, body function, activities, and participation during acute and convalescence phases but only the body function in the chronic phase.
Can on-top plasty for atypical radial polydactyly realize a functional reconstruction corresponding to appearance?

Hidemasa Yoneda, Tatsuya Hara, Katsuyuki Iwatsuki, Michiro Yamamoto, Masahiro Tatebe and Hitoshi Hirata
pg(s) 705–715

<Abstract> - < PDF >

On-top plasty may be the best option for reconstructing atypical radial polydactyly, consisting of a developed distal portion in one thumb and a developed proximal portion in the other thumb. However, it is unclear if patients can gain thumb function corresponding to the reconstructed appearance. We performed a retrospective bibliographic review to summarize the current literature and present our department’s on-top plasty experiences. Over the last ten years, our department performed three on-top plasty radial polydactyly reconstructions. We surveyed the appearance and use of the reconstructed thumb and the patient’s satisfaction level during postoperative follow-up. We also retrieved published case reports describing on-top plasty for polydactyly reconstruction to compare with our cases. Our patients had an acceptable thumb appearance and were satisfied with the gained function of the thumb. However, two patients required revision surgery. We found 11 studies in the literature describing on-top plasty for polydactyly treatment, four of which reported a limited range of thumb motion, but no patient or their family complained about the result. Most patients who undergo on-top plasty for radial polydactyly can expect a fair to good appearance after surgery. Although instability or limitation of the joint arc is possible, the reconstruction satisfies patients regarding function and appearance.


Circumumbilical incision for neonatal abdominal surgery: additional skin incision when there is difficulty in manipulating the intestine

Yoichi Nakagawa, Akinari Hinoki, Hizuru Amano, Hiroo Uchida, Chiyoe Shirota, Takahisa Tainaka, Wataru Sumida, Kazuki Yokota, Satoshi Makita, Masamune Okamoto, Aitaro Takimoto, Akihiro Yasui, Shunya Takada and Daiki Kato
pg(s) 716–722

<Abstract> - < PDF >

This study aimed to evaluate the safety and effectiveness of circumumbilical incision (CUI) for neonates requiring intestinal anastomosis. Seventy neonates requiring intestinal anastomosis at our institution between 2003 and 2020 were included in this retrospective case-control study. Patients were classified into the CUI (25 patients: 36%) and transverse incision (TI) groups (45 patients: 64%). Postoperative complications and surgical outcomes were compared between the two groups. Intestinal perforation at the non-anastomotic site occurred significantly more often in the CUI group than in the TI group (3 patients: 12%, and 0 patients: 0%, respectively (p = 0.042)). There were no between-group differences regarding anastomotic leakages, anastomotic strictures, time to enteral feeding, operative time, and blood loss. Neonatal intestinal surgery employing CUI might be associated with increased intestinal perforation at the non-anastomotic site. Hesitating to enlarge the skin incision to maintain favorable cosmetic outcomes might cause severe injury to the delicate neonatal intestine during the surgical procedure owing to the restricted surgical field. When performing CUI, we suggest that the skin incision should be extended without hesitation whenever there is difficulty in manipulating the intestine.
Prognostic efficacy of a post-discharge visiting program for patients with heart failure

Kenichiro Yasuda, Mitsutoshi Oguri, Takeshi Katagiri, Shiou Ohguchi, Kunihiko Takahara, Hiroshi Takahashi, Hideki Ishii and Toyoaki Murohara
pg(s) 723–732

<Abstract> - < PDF >

We aimed to investigate the impact of post-discharge scheduled hospital visits on readmission due to heart failure (HF). In this retrospective study, a total of 245 patients (N = 101 in the scheduled hospital visit group, N = 144 in the non-scheduled hospital visit group) who were alive with free from readmission due to HF for 90 days after discharge were enrolled. The patients had been hospitalized with acute decompensated HF between August 2018 and July 2019. Scheduled hospital visits were recommended 90 days after the patients had been discharged. After checking their self-care adherence, nurse-led self-care maintenance and monitoring were provided. To determine the effectiveness of the scheduled hospital visits, we conducted landmark analyses divided into two periods: Scheduled visits within 180 days, and after 180 days. The readmission rate due to HF within 180 days was lower in the scheduled visit group. In the landmark analysis, the 1-year incidence rate of readmission was significantly lower in patients with a scheduled hospital visit than in those without, in the period within 180 days (2.0% vs 9.0%, P = 0.029) but not after 180 days. After adjusting for age and estimated glomerular filtration rate as confounders, scheduled hospital visits tended to reduce readmission due to HF (P = 0.060); however, readmission was significantly reduced in the period within 180 days (P = 0.007). In conclusion, scheduled hospital visits at 90 days after discharge may be beneficial in delaying readmission due to HF by reducing risk of readmission during the early post-visit period.
Analysis of immunologic comorbidities in ulcerative colitis patients: a tool to prevent exacerbations in ulcerative colitis cases

Miguel Ricardo Rodríguez Meza, Masanao Nakamura, Takeshi Yamamura, Keiko Maeda, Tsunaki Sawada, Eri Ishikawa, Naomi Kakushima, Kazuhiro Furukawa, Tadashi Iida, Yasuyuki Mizutani, Takuya Ishikawa, Eizaburo Ohno, Takashi Honda, Hiroki Kawashima and Masatoshi Ishigami
pg(s) 733–745

<Abstract> - < PDF >

There have been previous studies, especially in Western countries and even in some areas in Asia, about extra-intestinal manifestations (EIMs) and its link with the outcome of inflammatory bowel disease (IBD), which includes Crohn’s disease (CD), and ulcerative colitis (UC). This link is crucial when discussing a patient’s prognosis and important when dealing with UC management. The aim of this study was to clarify the most common comorbidities associated with UC, emphasizing immunologic comorbidities in Japan. This study was a retrospective analysis performed at Nagoya University Hospital. The data collection started in March, 2019, and continued for two years. We retrieved the medical records of 105 patients with UC diagnosis, from which the data of 176 EIMs were extracted and analyzed. Results showed that EIMs with UC in the active phase accounted for 43.7% of total EIMs. Twenty-six patients with immune-mediated inflammatory disease frequently had an active phase (odds ratio [OR] 3.84, 99% CI, 1.44–10.27). Comorbidities showing an active manifestation of symptoms and UC in the active phase were significantly correlated in patients with immunological comorbidities, such as peripheral arthritis (r = 0.97, p < 0.01) and rheumatoid arthritis (RA) (r = 0.99, p < 0.01), as well as in patients with primary sclerosis cholangitis (PSC) (r = 0.98, p < 0.01). In conclusion, this analysis suggests the importance of having full comprehension of how immunological comorbidities affect the natural development of UC, which is of vital importance to prevent further UC complications and properly adjust the management of the disease.
A single-center, single-arm, prospective, open-label trial to evaluate the efficacy and safety of percutaneous sclerotherapy with polidocanol for painful venous malformations (SCIRO-2001): study protocol

Mayu Uka, Jun Sakurai, Yusuke Matsui, Toshihiro Iguchi, Koji Tomita, Noriyuki Umakoshi, Kazuaki Munetomo, Toshiharu Mitsuhashi, Hideo Gobara and Takao Hiraki
pg(s) 746–751

<Abstract> - < PDF >

This single-center, single-arm, prospective open-label trial is being conducted to evaluate the short-term efficacy and safety of percutaneous sclerotherapy with polidocanol foam for painful venous malformations. This study will include patients who were clinically diagnosed with venous malformation by using ultrasound and/or magnetic resonance imaging, and whose pain persisted even after treatment with medications. Written informed consent for sclerotherapy will be obtained from all patients. The institutional review board approved this prospective study protocol. The primary endpoint is pain relief at three months after sclerotherapy. Local pain related to venous malformation will be evaluated using a numeric rating scale. Patient recruitment commenced in December of 2020. Enrolment of 13 patients is planned over a 3-year recruitment period. Herein, we describe the details of the clinical trial protocol.
Incidence rate of chronic pain after 1.5–2 years of thoracotomy between paravertebral block versus epidural block: a cohort study

Reona Mori, Takahiro Tamura, Shuichi Yokota, Saya Usami, Masahiko Ando, Yoko Kubo and Kimitoshi Nishiwaki
pg(s) 752–761

<Abstract> - < PDF >

Paravertebral block and epidural block are frequently employed for post-thoracotomy pain relief. It is not clear which postoperative analgesia method is effective for the chronic pain after the postoperative long term progress. Our hypothesis was that paravertebral block would be more effective than epidural block for chronic pain 1.5–2 years after thoracotomy. A cohort study investigating postoperative pain was performed in lung cancer patients undergoing thoracotomy between the ages of 20–80 year-old, employed for another randomized controlled trial. In previously study, the patients were randomly allocated into either the epidural block or paravertebral block group (n = 36/group). Patients in each group received the respective block placement with continuous 0.2% ropivacaine infusion at 5 ml/h. The patients completed a telephone observational survey using the EQ-5D-5L at 1.5–2 years. Forty-eight patients, 23 in the epidural block group and 25 in the paravertebral block group, were included in the final analysis. Quality of life scores at 1.5–2 postoperative years was similar in both groups. Mean scores ± standard deviation and 95% confidence interval were 0.899 ± 0.081 (0.705–0.938) in the epidural block group and 0.905 ± 0.079 (0.713–0.938) in the paravertebral block group, respectively, p = 0.81. The incidence rate of chronic postsurgical pain was eight patients; four in the epidural block group (17.4%) and four in the paravertebral block group (16.0%). There was no difference in incidence rate of long-term chronic postsurgical pain at 1.5–2 years after thoracotomy between the both groups. Our result will be used for further study protocols.
Efficacy of comparing coil behavior and distribution using the silicone aneurysm model: difference of coil distribution in the early filling stage

Shunsaku Goto, Takashi Izumi, Masahiro Nishihori, Yoshio Araki, Kinya Yokoyama, Kenji Uda and Ryuta Saito
pg(s) 762–771

<Abstract> - < PDF >

This study sought to establish an experimental aneurysm model of visualizing coil insertion using radiolucent nylon coils. Moreover, this study aimed to clarify the characteristics and differences of each coil and use them clinically as indices of coil selection. The coil insertion test was performed on the 10 mm spherical silicone aneurysm model filled to a nylon coil volume embolization ratio of 11.8%. Five types of coil were randomly tested six times, and the distribution of the coils was analyzed by fluoroscopy imaging. Indices of “Area (mm2),” “Feret’s diameter (mm),” and “Circularity” were calculated from the fluoroscopic images. Among the indices, only “Area” showed a significant difference between coils (p = 0.002). On multivariate analysis, “Area” of the ED Infini was larger than those of Target XL soft and Galaxy G3 (p = 0.018 and 0.026, respectively). Furthermore, the area of the 360 soft was larger than that of G3 (p = 0.049). Analysis of the correlation between these values and the coil configuration showed that “Area” was negatively correlated with the stock-wire diameter (r = −0.50; p = 0.004) and primary coil configuration (r = −0.65; p < 0.001). When inserting the coils in the early stage, although the difference between each coil is relatively difficult to obtain, knowledge on the proper use of the coils with differences in characteristics can help in selecting the coil most appropriate for the conditions.
Examination of the effectiveness of bedside nasojejunal tube placement using a portable imaging device with a flat panel detector

Naohiro Takamoto, Shinya Takazawa, Yuki Yoshida, Tamotsu Sasaki and Akira Nishi
pg(s) 772–781

<Abstract> - < PDF >

Transporting pediatric patients with severe cardiovascular complications to the fluoroscopy room can be difficult. Therefore, we started using a portable imaging device with a flat panel detector (FPD) for nasojejunal tube (NJT) placement. The purpose of this study was to investigate the differences in length of time of NJT placement and dosage of radiation exposure using a portable imaging device with FPD versus fluoroscopy. Pediatric patients who underwent NJT placement between April 2016 and December 2018 were identified retrospectively from the clinical records. The age, sex, body weight, and height of each child at the time of the procedure as well as the procedure time, outcomes of the procedure, and dosage of radiation exposure was compared between the two groups. In 76 cases of NJT placement (41 patients), there was no significant difference in the success rate of NJT placement between the FPD (90%) and fluoroscopy groups (95%). However, the NJT placement time was significantly longer in the FPD group than in the fluoroscopy group (488 s vs 291 s). According to our calculations, the radiation dosage was lower in the FPD group than in the fluoroscopy group (136 μGy per procedure vs 2819 μGy per procedure). These results suggest that NJT placement using a portable imaging device with an FPD can be an effective method for children who are difficult to transport with an equal success rate and lower dosage of radiation exposure compared with conventional fluoroscopy.
Sex differences in blood pressure and inactive limb blood flow responses during dynamic leg exercise with increased inspiratory muscle work

Kana Shiozawa, Kaori Shimizu, Mitsuru Saito, Koji Ishida, Sahiro Mizuno and Keisho Katayama
pg(s) 782–798

<Abstract> - < PDF >

We hypothesized that, compared with young males, young females have a smaller decrease in blood flow to the inactive limb, accompanied by a smaller increase in arterial blood pressure, during dynamic exercise with increased inspiratory muscle work. Young males and females performed dynamic knee-extension and -flexion exercises for 10 min (spontaneous breathing for 5 min and voluntary hyperpnoea with or without inspiratory resistance for 5 min). Mean arterial blood pressure (MAP) and mean blood flow (MBF) in the brachial artery were continuously measured by means of finger photoplethysmography and Doppler ultrasound, respectively. No sex differences were found in the ΔMAP and ΔMBF (Δ: from baseline) during exercise without inspiratory resistance. In contrast, the ΔMAP during exercise with inspiratory resistive breathing was greater (P < 0.05) in males (+31.3 ± 2.1 mmHg, mean ± SE) than females (+18.9 ± 3.2 mmHg). The MBF during exercise with inspiratory resistance did not change in males (–4.4 ± 10.6 mL/min), whereas it significantly increased in females (+25.2 ± 15.4 mL/min). These results suggest that an attenuated inspiratory muscle-induced metaboreflex in young females affects blood flow distribution during submaximal dynamic leg exercise.
Locomotive syndrome in rheumatoid arthritis patients during the COVID-19 pandemic

Yasumori Sobue, Mochihito Suzuki, Yoshifumi Ohashi, Hiroshi Koshima, Nobuyuki Okui, Koji Funahashi, Hisato Ishikawa, Hidenori Inoue, Masayo Kojima, Shuji Asai, Kenya Terabe, Kyosuke Hattori, Kenji Kishimoto, Nobunori Takahashi, Shiro Imagama and Toshihisa Kojima
pg(s) 799–812

<Abstract> - < PDF >

This study aimed to longitudinally evaluate the development of locomotive syndrome (LS) in rheumatoid arthritis (RA) patients during the COVID-19 pandemic using the 25-question Geriatric Locomotive Function Scale (GLFS-25). Subjects were 286 RA patients (female, 70.6%; mean age, 64.2 years) who had GLFS-25 and Clinical Disease Activity Index (CDAI) data available for a 1-year period during the COVID-19 pandemic and who did not have LS at baseline. Associations between subject characteristics and development of LS were determined using logistic regression analysis. Among the 286 patients, 38 (13.3%, LS group) developed LS at 1 year after baseline. In the LS group, scores of the GLFS-25 categories “GLFS-5” and “Social activities” were significantly increased at 1 year relative to baseline. GLFS-5 is a quick 5-item version of the GLFS-25, including questions regarding the difficulty of going up and down stairs, walking briskly, distance able to walk without rest, difficulty carrying objects weighing 2 kg, and ability to carry out load-bearing tasks and housework. A significant correlation was also observed between changes in “Social activities” and that of “GLFS-5.” Multivariable logistic regression analysis revealed that the development of LS was significantly associated with BMI (OR: 1.11 [95% confidence interval (CI): 1.00–1.22]) and CDAI (OR: 1.08 [95%CI: 1.00–1.16]) at baseline. Adequate exercise and tight control of RA disease activity are important for preventing the development of LS in view of restrictions on going out imposed during the COVID-19 pandemic. GLFS-5 is useful for evaluating the physical function of RA patients.
The role of nursing members in research ethics committees in Japan

Yuki Sakaida, Katsumasa Ota and Chikako Sone
pg(s) 813–824

<Abstract> - < PDF >

The International Council of Nurses (2012) and the Council for International Organizations of Medical Sciences (2016) determined and published ethical standards relevant to nursing researchers and practitioners; based on these standards, nurses are expected to participate in committees where decisions on ethical issues are made. While clinical practitioners and nursing educators actively serve on research ethics committees, their precise role in these platforms has yet to be elucidated. In this study, medical, humanities/social science, lay, and nursing members in research ethics committees across Japan were invited to participate in a semi-structured interview; data were analyzed through a qualitative analysis method. Specifically, we interviewed 23 research ethics committee members in Japan to clarify the role of nursing members in the committee. Our qualitative analysis yielded six themes: share perspectives and experiences in nursing, protect research participants, evaluate the research design, represent the voice of research participants, confirm the informed consent documents and ascertain research participants’ free will. The analyses revealed a slight difference between what other committee members expected of the role of nursing members and nursing members’ recognition of their own role. Nursing members make an important and independent contribution to ethics committees on deliberations and decision-making regarding research ethics. Within the context of research ethics committees, member selection and training are essential issues, and this study contributes to the literature by showing how these topics relate to the role of the research ethics committees and of their members.
The effects of ustekinumab on small intestinal lesions and stenotic lesions

Hirotaka Wada, Kentaro Murate, Masanao Nakamura, Kazuhiro Furukawa, Naomi Kakushima, Takeshi Yamamura, Keiko Maeda, Tsunaki Sawada, Eri Ishikawa, Takuya Ishikawa, Eizaburo Ohno, Takashi Honda, Hiroki Kawashima, Goro Nakayama, Norifumi Hattori, Shinichi Umeda and Masatoshi Ishigami
pg(s) 825–838

<Abstract> - < PDF >

Crohn’s disease patients suffer from symptoms originating from small bowel lesions, including strictures. As many of these patients also have a potential risk of surgery, it is important to consider various therapeutic strategies for small bowel lesions. We retrospectively analyzed the therapeutic effects of ustekinumab, interleukin-12 and -23 blocker, for small intestinal lesions and intestinal stenosis in order to contribute to the optimal management of Crohn’s disease. Patients who underwent total colonoscopy or small bowel endoscopy before and after the introduction of ustekinumab were enrolled in this study. The colonoscopy findings were evaluated by the simple endoscopic score for Crohn’s disease, and small bowel endoscopy findings were evaluated using the modified simple endoscopic score for Crohn’s disease. Endoscopic scores were compared before and after the introduction of ustekinumab and between the responders and non-responders to ustekinumab. Responders were defined as those whose Crohn’s disease activity index score at 24 weeks fell below 150 points, or those whose score decreased by more than 100 points from the pre-induction level. A total of 50 patients were enrolled in the study, and the number of responders was 35. Pre-induction simple endoscopic scores were lower for responders, but no significant difference was observed in the modified simple endoscopic scores. The total decrease in the endoscopic score was significantly higher in the responders for both the small and large intestine. Use of ustekinumab as a first-line treatment for patients with small bowel lesions or stricture-prone lesions may be a new treatment consideration in the future.
Evaluation of the serum zinc concentration in male infertility patients: an analysis of 2010 cases

Hatsuki Hibi, Mikiko Tokoro, Miho Sugie, Tadashi Ohori, Megumi Sonohara, Noritaka Fukunaga and Yoshimasa Asada
pg(s) 839–847

<Abstract> - < PDF >

Zinc is an important trace element, and its importance for male infertility has been reported. The aim of the study was to assess whether the serum zinc concentrations were related to semen quality in male infertility patients. In 2010 subjects who consulted at our male infertility clinic between November 2018 and May 2021, serum zinc concentrations were assessed along with age, sperm concentration, sperm motility, endocrine panel, and body mass index (BMI). A normal zinc concentration was observed in 1069 (53.2%), subclinical deficiency in 845 (42.0%), and deficiency in 79 subjects (3.9%). On the other hand, high a zinc level was observed in only 17 subjects (0.9%). The serum zinc concentration did not relate with age, sperm concentration, sperm motility, luteinizing hormone (LH), follicle stimulating hormone (FSH), testosterone, and body mass index (BMI). However, normozoospermic subjects showed significantly higher zinc concentrations than among azoospermic (included non-obstructive; NOA and obstructive; OA) and cryptozoospermic patients. Furthermore, the zinc concentration was lower in NOA subjects when comparing to oligozoospermia and/or asthenozoospermia. An association between zinc concentration and semen analysis remained unclear. This study was cross-sectional and retrospective, however, this is a largest investigation of the zinc concentration during reproductive life span in Japan. Further accumulation of cases are required to further examine the potential relationship between zinc concentration and semen quality.
Editors' Choice
Advantages of gasless single-port transumbilical extracorporeal laparoscopic-assisted appendectomy in the treatment of uncomplicated acute appendicitis in children in China: a multi-institutional retrospective study

Jian-Hua He, Yi-Peng Han, Tian Hang, Zhi-Cai Lin, Shi-Jiao Lu, Jian-Feng Wang and Zhi-Hua Hong
pg(s) 848–856

<Abstract> - < PDF >

Gasless transumbilical extracorporeal laparoscopic-assisted appendectomy is an approach used increasingly to treat uncomplicated acute appendicitis (UAA). However, there is limited information on its clinical effects and value in the Chinese pediatric population. This study retrospectively reviewed patients with UAA treated in two pediatric institutions from January 2018 through October 2021. Enrolled patients were divided into two groups by operative technique: gasless transumbilical laparoscopic-assisted appendectomy (gasless-TULAA, n=142) and conventional laparoscopic appendectomy (CLA, three-port, n=126). The perioperative clinical data, including age, sex, body mass index (BMI), operation time, time to postoperative ambulation, time to first postoperative exhaust, hospitalization expenses, and postoperative complications (incision infection, intestinal obstruction, and residual abdominal abscess), were compared between the two groups. Operations in both groups were successfully conducted without converting to open surgery. There were no significant differences (p > 0.05) in age and BMI in the two groups. Compared with CLA, gasless-TULAA showed significantly shorter operation time, earlier postoperative ambulation, shorter postoperative exhaust time, and lower hospital cost (p < 0.001). All patients were followed for 3 months, and postoperative complications were observed in three patients: two patients in the gasless-TULAA group (one with surgical wound effusion, one with intra-abdominal abscess), and one patient in the CLA group (surgical wound infection); there was no significant difference between the groups. Notably, 38 patients initially treated by gasless-TULAA were converted because of intraoperative factors. The gasless-TULAA technique had potential benefits: shortened operation time, better outcome, and greater cost-efficiency. These superiorities are worthy of future large-scale prospective study.


Effect of illness uncertainty on alanine transaminase levels and aspartate aminotransferase levels in patients with nonalcoholic fatty liver disease

Naoki Ozawa, Kazuki Sato, Ayumi Sugimura, Shigeyoshi Maki, Taku Tanaka, Kenta Yamamoto, Takanori Ito, Yoji Ishizu, Teiji Kuzuya, Takashi Honda, Masatoshi Ishigami, Mitsuhiro Fujishiro, Tetsuya Ishikawa and Shoko Ando
pg(s) 857–864

<Abstract> - < PDF >

Patients with nonalcoholic fatty liver disease (NAFLD) have illness uncertainty. The purpose of this longitudinal study was to investigate the effect of the degree of illness uncertainty in patients with NAFLD on liver function values. We conducted a questionnaire survey and collected blood samples from outpatients with NAFLD. The items in the questionnaire were measured for illness uncertainty using the Japanese version of the Mishel Uncertainty in Illness Scale-Community (MUIS-C). Blood samples were collected at baseline and after 1 year. We divided the patients into two groups: one with high illness uncertainty and the other with low illness uncertainty. We then compared changes in alanine transaminase (ALT) and aspartate aminotransferase (AST) levels over time from baseline using multiple regression analysis. This study analyzed 148 patients with NAFLD; 75 were male and 73 were female, with a mean age of 58.4 ± 12.3 years. The group with higher illness uncertainty had significantly higher ALT and AST levels at 1 year (β = .185 and .183, respectively) than the group with lower illness uncertainty. High illness uncertainty in patients with NAFLD can lead to higher ALT and AST levels. Healthcare providers must focus on reducing illness uncertainty in patients with NAFLD.


A case of undifferentiated carcinoma of the bladder treated by combination therapy of surgery, local radiation, and immune checkpoint inhibitors

Wataru Nakane, Yushi Naito, Koya Morishita, Kazuna Matsuo, Shohei Ishida and Yoshihisa Matsukawa
pg(s) 865–870

<Abstract> - < PDF >

Undifferentiated carcinoma of the bladder is a rare malignancy with a poor prognosis. We present the case of an 81-year-old woman complaining of bladder irritation. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a bulky bladder tumor, which was diagnosed as cT4aN0M0. A transurethral resection of the bladder tumor revealed pT2 or higher urothelial carcinoma. The patient underwent total cystectomy with an ileal conduit diversion. Histological examination revealed a primary undifferentiated bladder carcinoma with a sarcoma component, pT3aN0M0. Postoperative adjuvant chemotherapy with gemcitabine plus carboplatin was administered. However, this regimen was discontinued after one course due to significant myelosuppression. Four months after total cystectomy, a pelvic tumor with suspected local recurrence was detected on CT. The patient was diagnosed with recurrent undifferentiated carcinoma with a sarcoma component by a transperineal ultrasound-guided biopsy. Local radiation therapy and immunotherapy with immune checkpoint inhibitors were prescribed. After three courses of immunotherapy with pembrolizumab, the primary tumor disappeared. Upon continuing immune checkpoint inhibitor treatment, the patient has maintained a complete response without tumor recurrence in the following six months.
PTPN11 c.853T>C (p.Phe285Leu) mutation in Noonan syndrome with chylothorax

Daisuke Watanabe, Yohei Hasebe, Shin Kasai, Tamao Shinohara, Yuki Maebayashi, Nobuyuki Katsumata, Atsushi Nemoto and Atsushi Naitoh
pg(s) 871–876

<Abstract> - < PDF >

Recent advances in molecular and genetic approaches have identified a number of genes responsible for Noonan syndrome (NS). However, there has been limited analysis of the genotype-phenotype correlation of NS patients. Here, we report the case of a Japanese patient with NS possessing a c.853T>C (p.Phe285Leu) mutation in the gene encoding protein-tyrosine phosphatase, nonreceptor-type 11 (PTPN11). To clarify genotype-phenotype correlations, the accumulation of data on the clinical course of patients with genetically confirmed NS is important. We summarized the cases with mutations at PTPN11 position 285 and found that c854T>C (p.Phe285Ser) is the most common mutation at this position. In these reports, although little is mentioned about the genotype-phenotype correlation, two patients with NS possessing the PTPN11 c854T>C (p.Phe285Ser) mutation accompanied by chylothorax are described. There is still a lack of detailed information about the phenotype associated with the c.853T>C (p.Phe285Leu) mutation observed in this case. More research is needed to better understand these cases.
Posterior ischemic optic neuropathy following postoperative bleeding and internal jugular vein compression

Keishi Kohyama, Hisakazu Kato, Masashi Kuroki, Hiroshi Okuda, Hirofumi Shibata, Toshimitsu Ohashi and Takenori Ogawa
pg(s) 877–883

<Abstract> - < PDF >

Perioperative blindness, especially posterior ischemic optic neuropathy (PION), is an uncommon but potentially devastating complication. We report a case of a 65-year-old male patient who underwent laryngopharyngectomy, bilateral neck dissection, and free jejunum flap reconstruction, but then experienced PION in his right eye following postoperative bleeding and bilateral internal jugular veins (IJVs) compression. Despite systemic corticosteroid therapy, his visual recovery prognosis was poor. The specific mechanism responsible for PION remains unclear, and no therapy has been shown to improve this condition. As such, prevention of perioperative PION remains the only available strategy. Surgeons should be aware of this rare potential complication and its risk factors and strive to avoid it. As postoperative bleeding and IJV compression are one of important risk factors for PION, avoiding these are critical.
Abnormal foreshortening of a Flow Re-Direction Endoluminal Device caused by in-stent thrombosis immediately after deployment

Takafumi Otsuka, Takashi Izumi, Masahiro Nishihori, Tetsuya Tsukada, Shunsaku Goto, Mizuka Ikezawa, Naoki Kato, Mizuki Nakano, Kenji Uda, Kinya Yokoyama, Yoshio Araki and Ryuta Saito
pg(s) 884–889

<Abstract> - < PDF >

Thromboembolic complications are a concern in the treatment of cerebral aneurysms using a flow diverter. In this study, we report a case of abnormal foreshortening of a Flow Re-Direction Endoluminal Device (FRED) caused by in-stent thrombosis immediately after its deployment. A 72-year-old woman had a large cavernous carotid aneurysm, which caused ptosis and diplopia. FRED deployment was planned, and dual antiplatelet therapy was initiated 2 weeks before the procedure. Under systemic heparinization, FRED was deployed with local compaction over the aneurysm orifice. Cone-beam computed tomography subsequently revealed slightly poor wall apposition at the proximal side. While the balloon catheter was prepared for angioplasty, the stent became abnormally foreshortened, the proximal side slipped into the aneurysm, and the internal carotid artery became occluded. FRED was removed using a snare wire, and recanalization was obtained. The lumen of the removed FRED was filled with thrombus. The antiplatelet therapy was changed to triple regimen, and a Pipeline Flex embolization device was placed 1 month later. At that time, no thromboembolic complications were noted. It was considered that thrombotic occlusion was followed by foreshortening of FRED on the distal side because of antegrade blood flow. Multiple factors, such as increased mesh density by locally compacted stent deployment, slightly poor wall apposition, clopidogrel resistance, and the dual-layer structure of FRED, may have been involved in thrombus formation.
Editors' Choice
Surgical removal of an intracranially migrated acupuncture needle: a case report and literature review

Daishiro Abe, Yoshiki Hanaoka, Kentaro Kobayashi, Takafumi Kiuchi, Tomofumi Watanabe, Sumio Kobayashi, Toshihiro Ogiwara and Tetsuyoshi Horiuchi
pg(s) 890–899

<Abstract> - < PDF >

Acupuncture is a popular alternative therapy worldwide and is generally safe. However, serious acupuncture-related complications can occur. Intracranial complications caused by a migrated acupuncture needle are extremely rare. Herein we report a surgical case of intracranial acupuncture needle migration and discuss the key technical aspects of the procedure. We additionally performed a review of the relevant literature. A 55-year-old woman presented with migration of a broken acupuncture needle via the posterior cervical skin. Computed tomography (CT) showed that the needle migrated intra- and extradurally via the atlanto-occipital junction. CT angiography revealed that the needle tail was located adjacent to the right distal horizontal loop of the vertebral artery. Meanwhile, the needle tip was positioned in the premedullary cistern adjacent to the medulla oblongata via the right lateral medullary cistern. Emergent surgical removal was conducted. Intradural exploration was required as the needle was not found in the epidural space. The needle penetrated the adventitia of the right intradural vertebral artery. We failed to pull out the needle toward the epidural space. After the needle was completely pulled into the intradural space, it was successfully removed without bleeding complication. Postoperative CT showed no evidence of residual needle fragment. The patient was discharged home without any sequelae. To the best of our knowledge, this is the first case of penetrating vertebral artery injury caused by radiologically confirmed acupuncture needle migration. An intracranially migrated needle should be removed urgently to prevent further migration causing brainstem, cranial nerve, and vessel injuries. The surgical strategy should be selected according to needle location and direction.
Primary laryngeal cryptococcosis mimicking laryngeal malignancy: a case report

Kazuya Tonai, Naoki Nishio, Sayaka Yokoi, Masumi Kobayashi and Michihiko Sone
pg(s) 900–905

<Abstract> - < PDF >

Primary laryngeal cryptococcosis is an extremely rare infection and presents with non-specific symptoms such as hoarseness or sore throat, resulting in delayed diagnosis. Here, we report the patient of a 56-year-old female patient with primary laryngeal cryptococcosis, who was being treated with oral and inhaled steroids for rheumatoid arthritis and bronchial asthma. The patient suffered from prolonged hoarseness and sore throat, and endoscopic biopsy was performed several times under local anesthesia, demonstrating only inflammatory cell infiltration. Considering the possibility of laryngeal malignancy, a third biopsy was performed by endoscopic laryngomicrosurgery under general anesthesia. Intraoperative frozen section revealed non-neoplastic laryngeal mucosa with erosion and severe inflammatory cell infiltration. However, we could not confirm the definite diagnosis of the lesion in the intraoperative consultation. Postoperative histopathological examination revealed a small number of yeast-type fungi and a definitive diagnosis was established by special stains including Alcian blue stain. Finally, the patient was diagnosed as primary laryngeal cryptococcosis. Daily oral administration of fluconazole (400 mg/day) was performed for 6 months according to the treatment protocol for pulmonary cryptococcosis. The symptoms gradually improved, and endoscopy revealed no recurrence 6 months post-treatment. Clinicians should consider the possibility of laryngeal cryptococcosis when severe inflammation is found in the larynx and discuss the disease history and pathological results with pathologists more closely.