Nagoya Journal of Medical Science

According to the Japanese Association for Thoracic Surgery annual surgery survey, the number of aortic surgery has been increasing constantly in the last two decades, with the rates approximately doubling in each decade (5,167, 11,956, and 22,708 cases in 1999, 2009, and 2019, respectively). In 2019, aortic surgery was performed for 11,036 (49%) nondissecting unruptured aneurysm, 730 (3%) ruptured aneurysm, 6,351 (28%) acute type A aortic dissection, 1,412 (6%) chronic type A aortic dissection, 2,385 (11%) acute type B aortic dissection, and 703 (3%) chronic type B aortic dissection cases. The outcomes have been improving annually. From 1999 to 2019, the hospital mortality rates decreased significantly in each case: nondissecting unruptured aneurysm, 9.8% to 4.2%; ruptured aneurysm, 38.5% to 19.7%; acute type A aortic dissection, 18.7% to 10.4%; chronic type A aortic dissection, 7.2% to 4.5%; acute type B aortic dissection, 25.2% to 9.8%; and chronic type B aortic dissection, 7.5% to 3.4%. Furthermore, stent graft, a new technology developed in 1990, was performed in 35%, 53%, 1%, 21%, 62%, and 75% of cases mentioned above, respectively, in 2019. The widespread use of stent graft greatly contributed to the increased number of aortic surgeries and improvement of surgical outcomes.

Studies have suggested that the administration of epidural analgesia (Epi) and oxytocin (OT) during labor affects offspring outcomes. However, the effects of their combined use remain unclear. This article aimed to review the outcomes of offspring exposed to Epi and OT, identify research gaps, and discuss future research directions. We searched the MEDLINE/PubMed, Web of Science, and Cochrane Library databases to identify studies describing offspring outcomes in the Epi, OT, Epi-OT, and control groups. We included one systematic review, six cohort studies, and one case-control study. The offspring outcomes at birth did not differ between the Epi-OT and Epi groups. In the first hour of life, the pre-feeding and sucking behaviors of the Epi-OT group showed an inverse correlation. At 2 days of age, the breastfeeding behavior and skin temperature patterns differed significantly between the Epi-OT and other groups. At 4 days of age, hyperbilirubinemia was more prevalent in the Epi-OT versus control group. Behavioral scores at 1 month differed little among the Epi-OT, Epi, and control groups. No eligible studies examined 1 month to 1 year of life. From 1 to >13 years of age, the risk of autism spectrum disorder was higher in the Epi and Epi-OT groups versus the control group. Most eligible studies were small and observational without randomization, and the results were inconsistent. Additional large cohort studies of various aspects of offspring development are required to assess the long-term effects of Epi-OT administration.

Afghanistan has an increasing trend of mortality due to non-communicable diseases but most studies were conducted in urban areas. This study aimed to assess the prevalence and factors associated with diabetes mellitus and hypertension in a rural area in Afghanistan. A cross-sectional study was conducted from September to October 2019 including 373 people who were 18–79 years old and lived in Andkhoy District, Afghanistan. Demographic and lifestyle data was collected by face-to-face interviews after informed consent was obtained. Height, body weight, blood pressure, waist circumference, and blood sugar level were measured by the data collection team. A logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). The prevalence of diabetes mellitus and hypertension was 9.7% and 29.5%, respectively. Factors associated with diabetes mellitus were male gender (adjusted OR [AOR]=9.81, 95% CI: 2.48–38.90), family history of diabetes mellitus (AOR=3.84, 95% CI: 1.30–11.38), low physical activity (AOR=4.53, 95% CI: 1.13–18.26), and high waist circumference (AOR=7.93, 95% CI: 2.40–26.20). Snuff users were negatively associated with diabetes mellitus (AOR=0.18, 95% CI: 0.04–0.75). Factors associated with hypertension were the age group of 40–59 years (AOR=4.22, 95% CI: 1.99–8.95) and 60–79 years (AOR=19.83, 95% CI: 7.19–54.71) compared to 18–39 years, family history of hypertension (AOR=2.17, 95% CI: 1.15–4.10), and palaw intake of 3 times per week or more (AOR=1.86, 95% CI: 1.03–3.38). Lifestyle interventions for increasing physical activity should be introduced and health education about snuff usage and salt intake should be promoted in communities in Afghanistan.

The 25-question Geriatric Locomotive Function Scale (GLFS-25) is a tool to identify locomotive syndrome, however, this tool is associated with the problem of a low complete response rate. We conducted this cross-sectional study of 2,474 community-dwelling residents to investigate the clinical characteristics of individuals who are prone to provide incomplete responses to the GLFS-25 questionnaire. The participants were divided into the following four groups based on the number of the GLFS-25 items they answered: 0 (n=279), 1–21 (n=36), 22–24 (n=273), and 25 (n=1,886). We investigated clinical characteristics including age, sex, body mass index, health consciousness, housemate status, smoking and drinking habits, physical activity level, the presence of body pain, and comorbidities. To achieve the study objective, we focused on a comparison of the clinical characteristics between the group of participants who answered 22–24 items (target group) and 0 items (control group). The participants who answered 22–24 items were older, more likely to be health-conscious, more likely to live alone, less likely to have lower levels of physical activity, and were more likely to report neck pain, low back pain, shoulder pain, elbow pain, wrist pain, hip pain, knee pain, ankle pain, and ophthalmic disease than those who answered 0 items. Among the significant factors, the only factor that can be changed to improve the number of answered items on the GLFS-25 is health consciousness.

Risk-adapted stereotactic body radiation therapy is preferred over conventional radiotherapy at the authors’ institution based on the hypothesis that even with a lower than recommended dose, stereotactic body radiation therapy would yield better local control than conventional radiotherapy. This retrospective study was performed to verify the hypothesis. Data from 34 patients with non-small cell lung cancer, who underwent risk-adapted stereotactic body radiation therapy delivered in 4 fractions between 2012 and 2018, were analyzed. The 3-year local control rate for patients receiving 42–44 Gy, 40 Gy, and 32–38 Gy was 80.8%, 75.0%, and 66.7%, respectively. The 3-year overall survival rate was 63.5%, 63.5%, and 40.0%, respectively. Three patients experienced grade 3 toxicities, with no toxicities > grade 3 observed. The results support the use of risk-adapted stereotactic body radiation therapy, both with a relatively high dose and a low dose.

The anatomical characteristics of middle cerebral artery aneurysms make endovascular treatment difficult. This study evaluated the efficacy and safety of endovascular treatment of unruptured middle cerebral artery aneurysm in preventing rupture. A retrospective review of patients who underwent coil embolization for unruptured middle cerebral artery aneurysm between 2006 and 2022 at Nagoya University Hospital with at least 12 months followed up was conducted. Imaging and clinical outcomes were described using the Raymond classification and the modified Rankin Scale, respectively. Good imaging outcome was defined as complete occlusion or neck remnant and clinical outcome as modified Rankin Scale score of 0–2. Patients were divided into initial and recurrent group based on the number of treatments, pre- and post-stent groups based on when stents became available in Japan. A total of 77 patients (80 with aneurysms) were included in the final analysis. Their average age was 60.3 years, and their average follow-up period was 38 months. Favorable clinical outcomes were achieved for 96.2% among 66 (97.0%) initial and 11 (91.7%) recurrent aneurysms. Furthermore, good imaging outcomes were obtained in 90.0 %, and 5% had permanent symptomatic ischemic complications. The pre-stent group had a significantly higher proportion of patients with narrow-neck aneurysms than the post-stent group. There were no significant differences in terms of imaging and clinical outcomes or complication rates. The present study demonstrated that endovascular treatment of unruptured middle cerebral artery aneurysm was safe and effective in preventing rupture. The wide-neck aneurysm was also well embolized by using adjunctive technique.

Small bowel stenosis in patients with Crohn’s disease leads to abdominal symptoms and can affect prognosis. The Simple Endoscopic Score for Crohn’s Disease for the large bowel has been applied to the small bowel; however, stenosis scoring may be overestimated since it has a long diameter. This retrospective study aimed to devise a new endoscopic scoring system including the small bowel and evaluate whether it predicts the prognosis of Crohn’s disease. The study included 103 patients with Crohn’s disease at our hospital. We modified the Simple Endoscopic Score for Crohn’s Disease and proposed a new scoring system; the modified applied Simple Endoscopic Score for Crohn’s Disease was created by subtracting one point for stricture from the Simple Endoscopic Score for Crohn’s Disease. Receiver operating characteristic curve analysis was performed to assess the accuracy of the modified applied score for Crohn’s disease in predicting disease worsening within 1 year. Results were validated using the log-rank test. For the modified applied score, the area under the receiver operating characteristic curve for disease worsening within 1 year in 57 cases was 0.850. When the cutoff score was set to 9 points, the sensitivity and specificity were 72.7% and 80.6%, respectively. The log-rank test showed a significant difference (P = 0.027) in the risk of worsening within 1 year between the low (<9 points) and high (≥9 points) score groups. Thus, a higher modified applied Simple Endoscopic Score for Crohn’s Disease may be associated with a significantly increased risk of disease worsening within 1 year.

Qualitative research, used to analyse non-numerical data including interview texts, is crucial in understanding medical education processes. However, it is often complex and time-consuming, leading to an interest in technology for streamlining the analysis. This study investigated the applicability of ChatGPT, a large language model, in thematic analysis for medical qualitative research. Previous research has used ChatGPT to explore the deductive process as a qualitative study. This study evaluated thematic analysis including the inductive process by ChatGPT with reference to human qualitative analysis. A convergent design mixed-methods study was used. Using a thematic analysis approach, ChatGPT (model: GPT-4) analysed some interview data from a previously published medical research article. The assessors evaluated the qualitative analysis of ChatGPT using human qualitative analysis as a benchmark. Three assessors compared the human-conducted and ChatGPT-driven qualitative analyses. ChatGPT scored higher in most aspects but showed variable transferability and mixed depth scores. In the integrated analysis including qualitative data, six themes were identified: superficial similarity of results with human analysis, good first impression, explicit association with data and process, contamination by directions in prompts, deficiency of thick descriptions based on context and research questions, and lack of theoretical derivation. ChatGPT excels at extracting key data points and summarising information; however, it is prone to prompt contamination, which necessitates careful scrutiny. To achieve deeper analysis, it is essential to supplement the research context with human input and explore the theoretical framework.

Postoperative atrial fibrillation complicates 15–40% of cardiac surgery cases and is associated with various adverse health outcomes including high mortality. Although vasopressin administration decreases postoperative atrial fibrillation in on-pump coronary artery bypass grafting, its use in off-pump coronary artery bypass grafting has not been investigated. Therefore, we evaluated the effect of vasopressin use in off-pump coronary artery bypass grafting. For this retrospective, observational study at a single-center community hospital in Yokkaichi, Japan, 298 patients who had undergone elective or emergency off-pump coronary artery bypass grafting between April 2015 and March 2021 were enrolled. Participants were divided into two groups: vasopressin and non-vasopressin groups. The outcomes in both groups were analyzed after propensity score matching, which revealed 40 patients in each matched group. Patients with chronic atrial fibrillation and those who were converted from off-pump to on-pump surgery were excluded. The primary outcome was postoperative atrial fibrillation occurrence within 4 days post-surgery. Secondary outcomes were 30-day mortality, intensive care unit and hospital stays, and postoperative complications (acute kidney injury, stroke, acute myocardial infarction, and respiratory complications). Although 11 patients (27.5%) in the vasopressin group were affected by postoperative atrial fibrillation when compared to 18 (45%) patients in the non-vasopressin groups, the difference was not significant (P=0.163). Similarly, no significant differences were observed in the secondary outcomes between groups. In off-pump coronary artery bypass grafting, vasopressin use may contribute to reduced postoperative atrial fibrillation; however, a large prospective study needs to be conducted for confirmation.

Selecting an appropriate microcatheter tip shape for paraclinoid aneurysms is difficult. Therefore, we devised an original simple and uniform three-dimensional (3D) spiral-shaping method of microcatheter and validated the characteristics and usefulness of this method for coil embolization of paraclinoid aneurysms using patient-specific silicone models. These silicone models were produced based on clinical data from four patients with four paraclinoid aneurysms that underwent endovascular treatment using the 3D spiral-shaping method. These models were classified into four types: superior, medial, inferior, and lateral corresponding to the aneurysm protrusion and locations (C3 or C2 segments by Fisher’s classification). Employing a pulsatile pump setup, two operators assessed the following items: navigation methods (pull and wire guiding), catheterization times, microcatheter tip position in the aneurysm, and the feasibility of inserting a framing coil by simple technique compared with three other shapes (straight, 90, pigtail). Three-dimensional spiral-shaped microcatheter could be placed in the medial and inferior type models of C3 segments and superior type model of C2 segment by the pullback method. Catheterization times using a 3D spiral-shaped catheter were significantly shorter than other shaped ones in the superior type models. No significant difference was found in another silicone model. Three-dimensional spiral- and pigtail-shaped catheters tended to position the tip at the center of the aneurysm. In conclusion, 3D spiral-shaped microcatheter was especially effective for the superior projected aneurysm at the C2 segment. The 3D spiral-shaping method can provide easy and secure navigation of the microcatheter into the paraclinoid aneurysms, ensuring optimal positioning for coil insertion.

Adenylate cyclase family members have recently received attention as novel therapeutic targets. However, the significance of adenylate cyclase 9 (ADCY9) in breast cancer has not been elucidated. Here, we evaluated ADCY9 expression in breast cancer (BC) cell lines, and polymerase chain reaction array analysis was performed to determine the correlations between ADCY9 expression levels and 84 tumor-associated genes. The association of ADCY9 messenger RNA (mRNA) expression levels in clinical breast cancer specimens with patients’ clinicopathological factors and prognosis was evaluated. The database of cancer cell line showed that estrogen receptor-positive and progesterone receptor-positive cells expressed higher ADCY9 mRNA levels. ADCY9 expression showed positive correlations with several oncogenes, such as TGFB1, CDKN1A, and BAX in the polymerase chain reaction array analysis. We defined the ratio of ADCY9 mRNA expression levels in breast cancer and adjacent noncancerous tissues as the “C/N ratio”. Among 149 patients with BC, estrogen receptor-positive and progesterone receptor-positive patients exhibited higher C/N ratios than estrogen receptor-negative and progesterone receptor-negative patients, respectively. Patients in the lowest C/N ratio quartile experienced shorter prognosis periods. The C/N ratio of ADCY9 was found as an independent prognostic factor for disease-free survival. Thus, ADCY9 expression is high in hormone receptor-positive breast cancer, and its low expression indicates a poor prognosis in patients with breast cancer.

Eggerthella lenta (E. lenta) is known to cause intra-abdominal and anaerobic bloodstream infections. However, clinical insights and information on antimicrobial susceptibility in E. lenta infections are limited. This study aimed to elucidate the clinical characteristics and antimicrobial susceptibility of E. lenta infections. Patients with E. lenta isolated from various specimens who presented at Aichi Medical University Hospital between January 2018 and December 2022 were included. Patient information was retrospectively collected from electronic medical records. Logistic regression analysis was conducted to identify risk factors for bloodstream infections. The antimicrobial susceptibility of various antimicrobial agents against isolated strains was investigated. During the study period, seventy cases were classified as infection cases. The median age of patients was 69 years (range: 15–100 years), and 48 (68.6%) were males. The most common site of infection was the lower digestive tract (54.3%). In 70.4% of cases, polymicrobial infections occurred. Community-acquired infection was a significant risk factor for bloodstream infection, with an odds ratio of 4.94 (95% confidence interval: 1.02–23.9). The 30-day mortality rate was 10.0%. Univariate analysis showed lower mortality in patients who underwent surgical intervention than in those who did not (42.9% vs 57.1%, p = 0.02). The proportion of minimal inhibitory concentrations (MICs) of ≥ 32 μg/mL for piperacillin-tazobactam was 6.3%. Additionally, the proportions of MICs of ≥ 8 μg/mL for imipenem and meropenem were 1.4% and 0%, respectively. E. lenta should be considered when blood cultures yield gram-positive rods in community-acquired intra-abdominal infections. Effective treatment involves both antimicrobial agents and surgical interventions.

Intracardiac migration of inferior vena cava (IVC) filter or stent is a rare but potentially fatal complication of endovascular venous device placement. There is no consensus whether migrated stents should be surgically removed by open cardiac surgery or retrieved by the percutaneous endovascular route and whether an intervention should be performed immediately or expectantly. Herein, we report a 39-year-old female who received emergent left lobe living donor liver transplantation (LDLT) owing to posthepatectomy liver failure. She underwent angioplasty for IVC stenosis 13 days after her LDLT during which time two IVC stents migrated into right antrum (RA). Because of acute kidney failure, she received perioperative continuous venous-venous hemofiltration. Owing to unstable hemodynamics and impaired liver graft function, an emergent open-heart operation or angiography to remove the migrated metallic stents in the RA was considered very high-risk. After recovery of liver graft and kidney function, she underwent an open-heart surgery to remove the intracardiac migrated IVC stents 40 days after the stent migration and recovered well. Our report is the first to show that a delayed open-heart operation for removal of migrated intracardial IVC stents can be an acceptable choice in selected LDLT recipients.

We report a case of a woman presenting with an erythematous finger nodule, with a history of exposure to tropical fish. The erythematous nodules subsequently spread proximally from the finger. Initial treatment with oral amoxicillin-clavulanate was unsuccessful, and she developed a drug eruption. Treatment with oral minocycline and thermotherapy was initiated, as we suspected infection with Mycobacterium marinum (M. marinum) from her history and clinical features. A culture from a skin biopsy from the finger grew M. marinum, confirming the diagnosis. There is no established treatment regimen for skin infections caused by M. marinum. In this case, it took time for cultures to confirm the diagnosis of non-tuberculous mycobacterial infection. While it would be ideal to await culture results, we felt it was better for the patient to initiate treatment, and in M. marinum infections, minocycline is considered particularly effective. However, it was envisaged that this would result in a prolonged treatment course, leading to potential resistance. Thermotherapy was added in an attempt to shorten the treatment period. This regime was successful, and the patient has remained free of recurrence since. The early initiation of treatment for cutaneous non-tuberculous mycobacterial infection requires aggressive suspicion. Also, testing, including adequate sampling and culturing, is essential for an accurate diagnosis. Slow-growing mycobacteria may take several months to be definitively diagnosed, as they grow only under certain conditions. Therefore, thorough clinical history-taking and information sharing with the microbiology team are essential. Our case illustrates this, and we believe this has important educational value.

A 54-year-old woman was referred to our hospital because of abnormal colonoscopic findings, including a submucosal protuberance at the appendiceal root. A biopsy showed no malignant findings. Computed tomography revealed a 20-mm cystic lesion with thick walls at the appendiceal root, suggestive of an appendiceal mucocele. Laparoscopic ileocecal resection was performed based on the preoperative diagnosis of a suspected mucinous appendiceal neoplasm. The resected specimen showed a closed appendiceal orifice surrounded by a mucus-containing submucosal tumor. Histopathologically, the appendiceal epithelium was circumferentially inverted in the appendiceal root, with hyperplasia of the submucosal connective tissue. No atypical epithelium was observed. We hypothesized that repeated partial invagination of the appendiceal root caused submucosal hyperplasia and drainage disturbance of the appendiceal content, leading to the development of a mucocele.

Ganglioneuromas are rare benign tumors that arise from the sympathetic nervous system. The presentation of tumors is variable and associated with adolescent thoracic scoliosis. Herein, we present two case reports and a review of literature. The two cases involved 10 and 13-year-old patients who were asymptomatic for muscle pain or weakness, and ganglioneuromas were incidentally detected through imaging screening. Both patients underwent a two-stage surgery. The first stage involved detachment of the tumor from the spinal cord and simultaneously performing deformity correction surgery from the posterior aspect. The second stage was resection of the ganglioneuroma through the anterior approach without neurological problems. A two-stage surgery was necessary to excise the tumor and correct the deformity, thereby avoiding neurological problems and concurrently establish a pathological diagnosis. Commencing with the posterior approach proved to be safe and was more effective.

Peribronchiolar metaplasia is an uncommon lesion characterized by fibrosis and bronchiolar epithelial cell proliferation along the peribronchiolar alveolar walls, primarily in response to bronchiolar and peribronchiolar injuries. Peribronchiolar metaplasia usually appears as ground glass nodules or sub-solid nodules on computed tomography. However, we present an exceptional case of peribronchiolar metaplasia that appeared as a solitary solid nodule on computed tomography. A 62-year-old woman with conjunctival icterus was diagnosed with ampullary cancer and nodal metastasis. A solid predominant nodule (0.7 cm maximum diameter) in the left lower lobe was identified on computed tomography, requiring accurate differentiation between primary lung cancer and pulmonary metastasis. Due to the location, histological confirmation via transbronchial biopsy was not feasible. Hence, the patient underwent surgery for both diagnosis and treatment. The pathological findings revealed the growth of columnar epithelium containing ciliated cells replacing alveolar epithelium in the bronchioloalveolar wall with no malignant component. The final pathological diagnosis of the lesion was peribronchiolar metaplasia. This unique case highlights an atypical presentation of peribronchiolar metaplasia as a solitary solid nodule on computed tomography. Recognizing that peribronchiolar metaplasia can also manifest as solid nodules, as illustrated in our current case, is essential.