Introduction and importanceA large hepatic cyst cause abdominal bloating and other symptoms. Surgical deroofing or ethanol sclerosis has been reported as the treatment options. We have treated patients surgically. However, an experience with postoperative bile leakage prompted us to reexamine our treatment options. It has been reported that the cause of bile leakage is the connection between the hepatic cyst and the bile duct. Therefore, we planned to observe the lumen of the hepatic cyst by endoscopy to evaluate the bile duct connection. Case presentationAn 82-year-old woman presented to our hospital for abdominal bloating. An abdominal computed tomography (CT) scan revealed a large hepatic cyst. Respiratory function was decreased due to diaphragmatic compression caused by the cyst. Endoscopic observation of the cyst was performed to evaluate the bile duct connection. There were no obvious abnormalities in her cyst. The patient was discharged 7 days after this procedure. Clinical discussionLaparoscopic deroofing is recommended for the treatment of a large hepatic cyst when a patient can take surgery. However, deroofing has the potential for postoperative bile leakage. Careful consideration should be given to the treatment approach for each patient. Ethanol sclerotherapy has the potential for recurrence, but in this case, we confirmed the absence of bile duct connection. The ethanol sclerosis was effective, and there was no postoperative bile leakage. ConclusionEndoscopic observation during puncture of the hepatic cyst allowed the evaluation of bile duct connection and search for malignant disease. Ethanol sclerotherapy was also effective.

This study aimed to evaluate the treatment outcome of osteonecrosis of the jaw （ONJ） in 18 patients receiving only denosumab. The patients comprised 11 males and seven females, with a median age of 82.5 years and mean age of 77.9 years. Fifteen patients were cancer patients with bone metastasis and three had osteoporosis. Stage 2 was the most common stage （77.8％）. Of the 18 patients, surgical treatment was performed in five patients, while purely conservative treatment was performed in 13. Surgical treatment achieved complete mucosal healing in 100％ （5/5） and was significantly correlated with treatment outcome on univariate analysis. In purely conservative treatment, two patients achieved complete mucosal healing and two patients achieved partial ONJ resolution. The treatment efficacy rate of conservative treatment was 30.8％ （4/13）. In four patients who were effectively treated by conservative treatment, their sequestrums detached spontaneously and epithelialized after a median of 12.5 months and mean of 15 months of discontinuing denosumab. ONJ progressed or was unchanged in five patients even after discontinuation of denosumab treatment. It may take a long time even if conservative treatment is successful. We recommend surgical treatment even for denosumab related osteonecrosis of the jaw when patients can tolerate surgery.

Abstract Coronavirus disease 2019 (COVID-19) is a pandemic infectious illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although evidence associated with SARS-CoV-2 infection in children is increasing but the pathogenesis and mechanism of disease progression are not fully understood yet. This study aimed to elucidate nasal swab gene expression profiles in children with SARS-CoV-2 infection. Using six publicly available nasal swab RNA-Seq datasets for pediatric patients (0–20 years old), we performed bioinformatics analyses on 223 patients, including 56 pediatric SARS-CoV-2 infected patients and 167 controls. We divided the patients into three groups according to their ages (0–4, 5–10, 11–20-year-old) and detected 44 differentially expressed genes in patients with SARS-CoV-2 infection. Pathway analysis revealed that these genes are associated with defense responses to viruses and innate immune responses. Among these 44 genes, we identified four representative genes (OSBPL8, RELCH, NUPR1, and RUBCN) that were novel and strongly associated with SARS-CoV-2 infection in children. Our study suggests that the expressions of these genes in nasal lesions may contribute to the pathogenesis of COVID-19, which is specific to children.

Several studies have investigated the potential effects of hyponatremia on recurrent febrile seizures (RFS) during febrile illness. Because findings were inconsistent across studies, we aimed to evaluate the serum sodium levels in febrile seizures (FS) of children with or without RFS during the same episode.We conducted electronic searches in three databases (PubMed, EMBASE, Cochrane Library) and one scholarly search engine (Google Scholar) up to June 2021 for studies on FS. Screening was done based on the titles and abstracts of primary studies. Then, eligibility was reviewed based on the abstracts. Finally, in order to match the inclusion and exclusion criteria, full-text articles were evaluated by two authors and inconsistencies were discussed. Data extraction was carried out by two independent authors. The extracted variables were author's name, article title, journal name, year of publication, study location, study design, sample size, and mean and standard deviation of blood Na concentration in FS. We performed a risk of bias assessment of included studies using the Newcastle-Ottawa Scale (NOS). The effect size was calculated using the standardized mean difference (SMD), and random-effects models were used for the analysis.A total of 12 articles were included with a single outlier. This analysis suggested that serum sodium level was lower in patients with RFS during the same febrile episode than in those with single FS, with SMD of -0.70, (n=1784; 95% CI: -1.03, -0.36; Z=-4.10, p<0.01; I2 86.67%, p<0.01). In the sensitivity analysis, no significant change was observed in pooled SMD. The optimal cutoff value of serum sodium level was 134.72 mmol/L with an area under the receiver operating characteristic curve of 0.81 (95% CI: 0.61, 1.00), with sensitivity of 80.0% and specificity of 70.0%.This result indicated a significant association between hyponatremia and RFS during the same febrile episode. Decreased serum sodium levels may be involved in seizure recurrence and may play a role in FS pathogenesis.

Retrospective multicenter study. Posterior decompression surgery for cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL) is a common surgery; however, it can cause postoperative cervical deformity (CD). The purpose of this study was to investigate the risk factors for CD. The participants were 193 patients underwent laminoplasty or laminectomy for CSM or OPLL. CD was defined as a C2-7 sagittal vertical axis (SVA) ≥ 40 mm or a cervical lordosis angle (CL) ≤ -10°. The participants were divided into 2 groups: NCD (without CD before surgery), CD (with CD before surgery). NCD group was divided based on the presence of CD 1 year after surgery as follows: postoperative CD (PCD) and no PCD (NPCD). There were 153 patients (NCD), 40 (CD), 126 (NPCD), and 27 (PCD). There was significant difference in the number of decompressed lamina (NPCD: PCD = 4.1:4.5), the presence of C2 decompression (2: 11%), and C5 palsy (0: 11%). The risk factors for onset of CD, PCD, and CL ≤ -10° as assessed by multiple logistic regression analysis were preoperative C2-7 SVA ≥ 30 mm (odds ratio [OR]: 19.0), decompression of C2 or C7 lamina (OR 3.1), and preoperative CL ≤ 2° (OR 42.0), respectively. To prevent postoperative CD, it is important to avoid decompression of the C2 or C7 lamina. Moreover, in case with C2-7 SVA ≥ 30 mm or CL ≤ 2° before surgery, it is important to explain the risks and consider adding fusion surgery.

Retrospective longitudinal cohort study. To investigate postoperative medical complications in patients with malnutrition after cervical posterior surgery. A total of 256 patients were participated and divided into PNI < 50 group (group L) or PNI ≥ 50 (group H). Patient data, preoperative laboratory data, surgical data, hospitalization data, JOA score, complication data were measured. Group L and group H were 127 and 129 patients, each PNI was L: 44.8 ± 4.3, H: 54.6 ± 4.0, P < 0.01. There was significant difference in mean age (L: 72.2 years vs H: 64.8 years, P < 0.01), BMI (23.1 vs 24.7, P < 0.01), serum albumin (L: 3.9 ± 0.4 g/dl vs H: 4.4 ± 0.3 g/dl, P < 0.01), total lymphocyte count (L: 1.3 ± 0.5 103/µL vs H: 2.1 ± 0.7 103/μL, P < 0.01), hospital stay (L: 25.0 days vs H: 18.8 days, P < 0.05), discharge to home (87.5% vs 57.5%, P < 0.01), delirium (L: 15.9% vs H: 3.9%, P < 0.01), medical complications (L: 25.2% vs H: 7.0%, P < 0.01), pre- and post- operative JOA score (L: 11.3 ± 2.8 vs H: 12.4 ± 2.6, P < 0.01; L: 13.3 ± 3.0 vs H: 14.1 ± 2.4, P = 0.02). Multiple logistic regression analysis showed that significant risk factors for medical complications were PNI<50 (P = 0.024, odds ratio [OR] 2.746, 95% confidence interval [CI] 1.143-6.600) and age (P = 0.005, odds ratio [OR] 1.064, 95% confidence interval [CI] 1.020-1.111). Medical complications are significantly higher in patients with PNI < 50 and higher age. The results showed that PNI is a good indicator for perioperative medical complications in cervical posterior surgery. Improvement of preoperative nutritional status is important to avoid medical complications. 3.

Background: Despite recognition of the importance of primary health care, the opportunities for medical students to participate in family medicine clerkships (FMCs) are still inadequate around the world. In order for FMCs to be accepted in the undergraduate curriculum, it is necessary to clarify whether FMCs complement clerkships at teaching hospitals.Methods: Throughout the academic year 2018–2019, a total of 125 fifth-year students in Fukushima Medical University participated in an FMC. The students evaluated themselves at the beginning and end of their FMC whilst the family doctors evaluated students at the end of the FMC. The evaluations were a 5-point scale on 31 items in the following seven areas; objectives in general practice, practical skills and patient care, communication skills, patient-physician relationship, practice of team-based health care, medical practice in society and medical knowledge and problem-solving ability. A multiple regression analysis was conducted to assess whether self-evaluation was increased by clerkships at teaching hospitals where students rotated before the start of FMC. A Wilcoxon signed-rank sum test was used to assess self-evaluation changes before and after the FMC.Results: All 125 students completed the study. Pre-FMC self-evaluation scores for 19 items tended to be higher depending on when the FMC was conducted; the later the semester, the higher the score (e.g. diagnostic reasoning: first semester, 2.23; second semester, 2.48 [p = 0.11]; third semester, 2.61 [p = 0.02]). However, this tendency was not observed in the remaining 12 items: psychological and social background, home medical care, interprofessional work, healthcare system, team-based health care, participate as a member of the team, role of the physician in team collaboration, current medical situation in the community, community-based integrated care system, necessity of primary care, discover necessary tasks, and rank the tasks. In post-FMC evaluation, six of the 12 items were higher than four point in both the self-evaluations and family doctor evaluations. A significant increase was observed between the pre-and post-FMC self-evaluation scores in all 31 items (e.g. diagnostic reasoning: pre 2.2 and post 3.9 [p <0.0001]).Conclusion: The results of the present study suggest that FMCs complement clerkships at teaching hospitals.