Osaka Medical College Research Articles

Progression of pancreatic branch duct-type intraductal papillary mucinous neoplasms (BD-IPMNs) after surgery for extrapancreatic malignancies

Background/aimsThe natural history of pancreatic branch duct-type intraductal papillary mucinous neoplasms (BD-IPMNs) is still unknown. This retrospective study aims to determine the morphological changes of BD-IPMNs with attention to the history of surgical resection for extrapancreatic malignancies.Methods and materialsThis study included 427 subjects with BD-IPMN at the Osaka Medical College from January 2001 to December 2019; 134 patients were included. The predictive factors for the progression of BD-IPMN based on morphological changes were evaluated by univariate as well as multivariate analyses. Furthermore, the clinical features of BD-IPMNs with progressive lesions during follow-up were investigated.ResultsThe average interval of follow-up was 35.8 months (with a range between 12.1 and 157 months). Disease progression occurred in 6 subjects (4.5%). In two of them (1.5%), IPMN-related invasive carcinoma was found. Multivariate analysis demonstrated that surgical resection for extrapancreatic malignancies was a significant predictor of BD-IPMN progression.ConclusionThe history of resection of extrapancreatic malignancies should be considered during the follow-up of BD-IPMN.

Fine-Needle Aspiration Cytology for Parotid Tumors.

Fine-needle aspiration (FNA) cytology is widely used in clinical practice as a simple and minimally invasive test for parotid tumors that allows for preoperative estimation of benignancy and malignancy, histological type, and malignancy grade and can be performed on an outpatient basis. In recent years, cell blocks prepared with core needle biopsy (CNB) and liquid-based cytology (LBC) have increased the reliability of immunostaining and molecular biological testing, leading to improved diagnostic accuracy. In 2018, the Milan System for Reporting Salivary Gland Cytology was introduced, but it does not include malignancy grade or histological type, so we proposed the Osaka Medical College classification as a more clinically based cell classification that includes both types of information, and we have reported on its usefulness. This review gives an overview of the history and use of FNA and describes CNB and LBC and the two classification systems.

Application of the Homologous Modeling Technique for Precision Medicine in the Field of Oral and Maxillofacial Surgery

In the field of oral and maxillofacial surgery, establishment of a new method for predicting morphology is desirable. Therefore, the purpose of the present study was to establish a new method for predicting the original shape of a mandibular defect site using the homologous modeling technique. This study used data from 44 patients who underwent computed tomography in the Department of Oral Surgery at Osaka Medical College. Two types of homologous models were constructed: total mandible (TM) and half mandible (HM). Principal component analysis (PCA) was performed using point cloud data of the homologous model M and homologous model HM, and a multiple regression equation was created using the PC value of TM as the object variable and PC value of HM as the explanatory variable. The predicted PC (M) was created from PC (HM) using a regression formula, back-calculated from point cloud data from PC (M), to create the predicted mandible model. Finally, the original image (TC-M) and estimated mandible were superposed and examined. The mean absolute error between the predicted mandible and actual mandible was 1.04 ± 1.35 mm. We believe that this method will be applicable in actual clinical practice.

Optimisation of Radiation Therapy in Bladder Preservation Therapy for Patients With Clinical Stage T2N0M0 Bladder Cancer

AimsA novel bladder preservation therapy, the OMC (Osaka Medical College) regimen, which combines radiation therapy with balloon-occluded arterial infusion of anticancer agents, is a treatment option for patients with muscle-invasive bladder cancer (MIBC). We retrospectively analysed the effects of changes in radiation dose and irradiation field on treatment efficacy and adverse events.The purpose of this study is to use the results of this study to help determine a course of radiation therapy for bladder preservation therapy of cT2N0M0 MIBC. Materials and methodsWe examined 352 patients with clinical stage T2N0M0 (cT2N0M0) MIBC classified into the following groups based on the irradiation method: group A, the whole pelvis (50 Gy/25 fractions) + local bladder (10 Gy/5 fractions); group B, the small pelvis (50 Gy/25 fractions) + local bladder (10 Gy/5 fractions); group C, the whole pelvis (40 Gy/20 fractions) + local bladder (10 Gy/5 fractions). ResultsThe complete response rate, 3-year overall survival and progression-free survival rates in group A were 92.9%, 94.9% and 82.1%, respectively; in group B were 87.2%, 86.7% and 76.7%, respectively; and in group C were 95.2%, 92.6% and 71.1%, respectively. No significant differences between the groups were noted. The incidence of ≥grade 3 urinary tract and gastrointestinal toxicities were not significantly different among the groups (group A: 7.8%, 1.7%; B, 11.1%, 0%; C, 7.1%, 1.8%, respectively). The 3-year progression-free rates of the common iliac lymph node (CILN) region in patients who received whole-pelvis and small-pelvis irradiation were 99.0 and 89.0% (P < 0.01), respectively, with the latter group having significantly high lymph node recurrence in the CILN region. ConclusionsOur findings showed that the optimal radiation therapy for patients with cT2N0M0 MIBC undergoing the OMC regimen is whole-pelvis irradiation including the CILN region, with a total dose of 50 Gy/25 fractions.

Weight and Abdominal Pressure-Induced Shunt Trouble in Patients With Shunted Normal Pressure Hydrocephalus: A Comprehensive Study on Pressure Environment of Shunt System.

ObjectivesWe identified a new type of shunt malfunction (SM) in patients with normal pressure hydrocephalus (NPH). It is induced by weight change and can be treated with valve readjustment. There were two types of SM as follows: Underdrainage induced by the weight gain and overdrainage induced by the weight loss. This study aims to elucidate this mechanism by assessing the shunt pressure environment.MethodsThe total pressure environment of the shunt system was prospectively studied in patients with shunted NPH at Osaka Medical College Hospital from 1999 to 2005. We measured the pressure environment during the initial pressure setting of the valve by the intracranial pressure (ICP) guide, after setting the valve, and when SM was suspected. We evaluated ICP, intra-abdominal pressure (IAP), and hydrostatic and perfusion pressures of the shunt system in the sitting and supine positions. The target ICP for valve setting was empirically set at the range from −8 to −13 mm Hg in the sitting position, referring to the external auditory meatus. During the study period, we identified five cases of SM induced by weight change and assessed the changes in the pressure environment across pre-SM, SM, and post-SM.ResultsIn four cases of underdrainage, gait disturbance worsened with an average weight gain of 6.8 ± 1.2 kg. With weight gain, IAP and ICP increased by 8.8 ± 1.6 and 4.8 ± 1.0 mm Hg, respectively. Consequently, ICP increased to −6.5 ± 1.9 mm Hg. One overdrainage patient developed an asymptomatic chronic subdural hematoma (CSDH) with a weight loss of 10 kg. With the weight loss, both IAP and ICP decreased by 5 mm Hg, and concomitantly, ICP decreased to −18 mm Hg. In all patients, the valve readjustment restored their ICP to the target pressure. After the valve readjustment, the gait disturbance improved immediately, and the CSDH disappeared after 1 month.ConclusionIn patients with shunts, the weight change was linked to ICP via IAP. Due to the weight change, the underdrainage occurred when ICP was above the target pressure, and the overdrainage occurred when ICP was below it. We named this SM as the weight and abdominal pressure-induced shunt trouble. The patients with SM along with weight changes should be the first to be tried for the valve readjustment.

Abstract P4-05-06: High absolute lymphocyte counts are associated with longer overall survival in patients with metastatic breast cancer treated with eribulin as the first-line chemotherpy. Combined analysis of two phase 2 study

Abstract Background: Eribulin demonstrated improving overall survival of HER2-negative metastatic breast cancer in EMBRACE trial. Recently, ad hoc analysis of the trial showed that immune response markers such as absolute lymphocyte count (ALC) was associated with prognosis. However, blood cell count must be influenced by previous chemotherapy because the trial was targeted for late-line treatment.Previously we had conducted two phase 2 trials that estimated efficacy of eribulin as the first-lien chemotherapy for HER2-negative metastatic breast cancer in Japan. Base line ALC and NLR were examined for the participants of these trials to determine whether they were also associated with prognosis in the first-line setting. Patients and Methods: A total of 59 patients were enrolled this study including 35 patients of BIRICHEN trial (UMIN000006086; SpringerPlus 2016;5:164) for only first-line chemotherapy with eribulin and 24 patients who treated as the first-line chemotherapy in OMC-BC03 trial targeted for first and second line chemotherapy (UMIN000009568; Cancer Chemother Pharmacol 2018; 81:923). Pretreatment blood cell counts were collected from case report form and compared with survival data. Cutoff value of ALC was set at 1500/mm3 and that of NLR was set at 3 in accordance with ad hoc analysis of EMBRACE trial. The ethics committees of Osaka Medical College and Osaka City University approved the present study. Results: Median value of ALC was 1690/mm3(Quartile Q1,Q3: 1014, 2012) and that of NLR was 2.17(Q1,Q3: 1.54, 2.99). In comparison with ALC, overall survival (OS) was 132.6 months in the ALC-high group(&amp;gt;=1500;n=33) versus 76.4 months in the ALC-low group (&amp;lt; 1500; n=26). Hazard ratio(HR) was 0.52(95%CI; 0.27-1.01) with border line significancy. Progression free survival(PFS) is 28.0 months in the ALC-high group versus 20.4 months in the ALC-low group. HR was 0.91(95% CI; 0,51-1.60) without statistically significant difference. In NLR, OS was 20.7 months in the NLR-low group(&amp;lt;3;n=45) versus 4.6 months in the NLR-high group. HR was 0.40 (95%CI; 018-0.90) with statistical significance. PFS was 6.2 months in the NLR-low group versus 10.8 months in the NLR-high group (&amp;gt;=3; n=14). HR was 0.57 (95%CI; 0.25-1.30) without statistically significant difference. Conclusions: In the post hoc analysis of the EMBRACE trial, patients who assigned eribulin group with ALC 1500 or higher had better OS than those with ALC less than 1500, but no difference was observed in PFS. In addition, those with NLR less than 3 had better PFS and OS than those with NLR 3 or more. In comparison with the capecitabine group, although low NLR was a good prognostic factor not only in eribulin group but also in capecitabine group, high ALC was suggested to be a particular prognostic factor of eribulin. However, since EMBRACE study was a late line setting, there could be an effect of myelosuppression by pretreatment. Our first-line results did not affect bone marrow function by prior chemotherapy, but similar results were obtained. ALC may be a prognostic factor of eribulin regardless of the treatment line, suggesting that eribulin exerts its effect by acting on the immune microenvironment. Citation Format: Tsutomu Takashima, Kosei Kimura, Hidemi Kawajiri, Shinichiro Kashiwagi, Shinya Tokunaga, Shigehiko Nishimura, Satoru Noda, Hiroyo Oku, Ayana Ikari, Tomo Tominaga, Saki Maezawa, Junna Sakane, Mitsuhiko Iwamoto. High absolute lymphocyte counts are associated with longer overall survival in patients with metastatic breast cancer treated with eribulin as the first-line chemotherpy. Combined analysis of two phase 2 study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-05-06.

Impacts of long-term coronavirus disease 2019 school closures on Japanese school children.

This study investigated the impact of coronavirus disease 2019 pandemic school closures on the mental health of school students with chronic diseases. Questionnaires were distributed to students from 4th-9th grade diagnosed with chronic diseases at Osaka Medical College Hospital and their parents or caregivers. Questionnaires from 286 families were returned by mail after the schools reopened. The students were divided into the "psychosomatic disorder" group (group P, n = 42), the "developmental disorder" group (group D, n = 89), and the "other disease" group (group O, n = 155). Using students' self-reports on the Questionnaire for Triage and Assessment with 30 items, we assessed the proportion of students with a high risk of psychosomatic disorder in three groups. We investigated how the students requiring the support of somatic symptom (SS) felt about school during school closure. Further, using parents' and caregivers' answers, SS scores were calculated before and during school closure and after school reopening. The proportion of students with a high risk of developing psychosomatic disorder increased in all groups. For the students in Group P, the response "I did not want to think about school" indicated an increase in SS scores, and for the students in Group O, "I wanted to get back to school soon" indicated a decrease. Furthermore, especially in Group P students, SS scores decreased transiently during school closure and increased after school reopening. The impact of school closure on mental health differed depending on students' diagnoses and feelings about school during school closures.

Three-Year Outcomes of Pars Plana Ahmed and Baerveldt Glaucoma Implantations for Neovascular Glaucoma in Japanese Eyes.

Tube shunt implantation through the pars plana was effective for neovascular glaucoma (NVG) for at least 3 years, with few serious postoperative complications observed. The aim was to report 3-year outcomes of pars plana Ahmed and Baerveldt glaucoma implantation for NVG in Japanese eyes. This study examined 41 eyes of 39 patients who underwent tube shunt implantation through the pars plana with the Baerveldt glaucoma implant (BGI group, 26 eyes) or Ahmed glaucoma valve (AGV group, 15 eyes) for NVG and who were followed up for over 3 years at Osaka Medical College between January 2009 and April 2016. Outcome measures were intraocular pressure (IOP, mm Hg) at presurgery and at 6 months and 1, 2, and 3 years postoperative. Postoperative failure was defined as an IOP of >21 mm Hg or <5 mm Hg, further glaucoma surgery, or no light perception. Mean IOPs at presurgery and at 3 years postoperative were 34.8±9.1 and 15.6±4.6 in the AGV group, and 36.9±9.2 and 12.8±5.5 in the BGI group. Mean antiglaucoma medication scores at 3 years postoperative were 1.3±1.4 in the AGV group and 0.4±0.8 in the BGI group (P=0.05). The number of eyes with a probability of failure at 6 months and at 2 and 3 years postoperative was 2, 3, and 4, respectively, in the BGI group, and 0, 1, and 2, respectively, in the AGV group. Findings for NVG cases showed tube shunt implantation through the pars plana was effective. Equivalent good IOP reductions were noted in both groups, with the BGI group requiring fewer postoperative antiglaucoma medications compared with the AGV group. Furthermore, both groups exhibited few serious postoperative complications.

Use of an artificial intelligence-based rule extraction approach to predict an emergency cesarean section.

ObjectiveOne of the major problems with artificial intelligence (AI) is that it is generally known as a “black box”. Therefore, the present study aimed to construct an emergency cesarean section (CS) prediction system using an AI‐based rule extraction approach as a “white box” to detect the cause for the emergency CS.MethodsData were collected from all perinatal records of all delivery outcomes at Osaka Medical College between December 2014 and July 2019. We identified the delivery method for all deliveries after 36 gestational weeks as either (1) vaginal delivery or scheduled CS, or (2) emergency CS. From among these, we selected 52 risk factors to feed into an AI‐based rule extraction algorithm to extract rules to predict an emergency CS.ResultsWe identified 1513 singleton deliveries (1285 [84.9%] vaginal deliveries, 228 emergency CS [15.1%]) and extracted 15 rules. We achieved an average accuracy of 81.90% using five‐fold cross‐validation and an area under the receiving operating characteristic curve of 71.46%.ConclusionTo our knowledge, this is the first study to use interpretable AI‐based rule extraction technology to predict an emergency CS. This system appears to be useful for identifying hidden factors for emergency CS.

Assessment of clinical factors affecting outcome of myasthenia gravis.

In myasthenia gravis (MG) therapy, achieving Myasthenia Gravis Foundation of America minimal manifestation (MM) or better status is proposed as a desirable target. However, this level of control is often not achieved and clinical factors affecting prognosis remain unclear. Participants were 104 consecutive patients with MG who visited Osaka Medical College Hospital. We retrospectively assessed the association of clinical and laboratory features at baseline with prognosis. Eighty patients who achieved MM or better status were classified as the good outcome group and the remaining 24 patients were classified as the poor outcome group. The rate of dysphagia at baseline was significantly higher in the poor outcome group than in the good outcome group (P=.002). The levels of serum total protein and albumin at baseline were both significantly lower in the poor outcome group than in the good outcome group (P=.036 and P=.014, respectively). In addition, Controlling Nutritional Status scores at baseline were significantly higher in the poor outcome group than in the good outcome group (P=.043). Multivariate analysis using a Cox proportional hazards model showed that dysphagia (hazard ratio [HR], 6.92; 95% confidence interval [CI], 1.49-40.31) and hypoalbuminemia (HR, 2.57; 95% CI, 1.04-6.57) at baseline were risk factors that predicted prognosis. These findings suggest that dysphagia and hypoalbuminemia at baseline are associated with outcomes and are predictive risk factors for poorer outcomes in patients with MG.

Regression Discontinuity of Blood Culture Contamination Rate After Changing of Disinfectants: Retrospective Observational Study

Background: Blood cultures are indispensable for detecting life-threatening bacteremia. Blood cultures can become contaminated, which increases health care costs and antimicrobial resistance. Little is known about associations between contamination rates and topical disinfectants for blood collection in adults. Objective: We sought to determine whether a change in topical disinfectants was associated with the rates of contaminated blood cultures in the emergency department of a single institution. Methods: This single-center, retrospective observational study of consecutive patients aged 20 years or older was conducted in the emergency department (ED) of a university hospital in Japan between August 1, 2018 and September 30, 2020. Pairs of blood samples were collected for aerobic and anaerobic culture from the patients in the ED. Physicians selected topical disinfectants according to their personal preference before September 1, 2019; alcohol/chlorhexidine gluconate (ACHX) was mandatory thereafter, unless the patient was allergic to alcohol. Regression discontinuity analysis was used to detect the effect of the mandatory usage of ACHX on rates of contaminated blood cultures. Results: We collected 2,141 blood culture samples from 1097 patients and found 164 (7.7%) potentially contaminated blood cultures. Among these, 445 (20.8%) were true bacteremia and 1,532 (71.6%) were true negatives. Puncture site disinfection was performed with ACHX for 1,345 (62.8%) cases and with povidone-iodine (PVI) for 767 (35.8%) cases. The regression discontinuity analysis showed that mandatory ACHX usage significantly reduced the blood culture contamination rate by 9.6% (95% confidence interval (CI): 5.0%–14.2%, P <0.001). Conclusion: Rates of contaminated blood cultures were significantly lower when ACHX was used as the topical disinfectant. Funding Statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of Interests: We have no conflicts of interest to disclose. Ethics Approval Statement: The Institutional Review Board at Osaka Medical College approved the study protocol (No. 675(2476)) and waived the need for written, informed consent.

Risk Factors and Prediction of Bleeding after Endoscopic Submucosal Dissection in Patients on Antithrombotic Therapy: The SAMURAI Model

Background: Bleeding after gastric endoscopic submucosal dissection (ESD) remains problematic, especially in patients receiving antithrombotic therapy. Thus, our study aimed to identify the risk factors and to create a prediction model for post-ESD bleeding in patients receiving antithrombotic therapy. Methods: Patients receiving antithrombotic therapy who underwent gastric ESD at Osaka Medical College Hospital and at 18 referral hospitals all over Japan were enrolled. Risks of post-ESD bleeding were calculated using multivariable logistic regression. The dataset was randomly divided into derivation cohort (70%) and validation cohort (30%). We created a prediction model using derivation cohort. The accuracy of the model was evaluated using the validation cohort. We compared this model with an existing scoring method, using NRI (net reclassification improvement) and IDI (integrated discrimination improvement). Findings: The study enrolled 1207 patients. Post-ESD bleeding occurred in 142 (11·8%) cases. Multivariable analysis yielded an odds ratio of 1·73 for aspirin, 4·18 for P2Y12 receptor antagonist, 1·42 for cilostazol, 0·80 for other antiplatelet agents, 4·12 for warfarin, 3·76 for dabigatran, 5·14 for apixaban, 6·74 for edoxaban, 4·22 for rivaroxaban, and 1·56 for heparin bridging. The prediction model (SAMURAI model) was created for patients receiving antithrombotic therapy, and it had a good predictive ability with a C-statistic of 0·74. The model had a significantly better predictive ability than a previously reported model (NRI=0·41, 0·15–0·66, p=0·002, IDI=0·05, 0·02–0·08, p=0·002). Interpretation: In this study, the risk of post-ESD bleeding for each antithrombotic agent was evaluated. Use of the SAMURAI model will allow the proactive management of post-ESD bleeding risk during antithrombotic therapy. Funding: 2nd Department of Internal Medicine, Osaka Medical College, Japan Declaration of Interest: The authors declare that there are no conflicts of interest associated with this manuscript. Ethical Approval: This study was conducted according to the guidelines of the Declaration of Helsinki. The study was approved by the Ethics Committee of Osaka Medical College (trial number: 693) and by the institutional review board of each participating institution before the recruitment of patients. Informed consent for this study was obtained in the form of opt-out on the website of each participating hospital. All authors had access to the study data and reviewed and approved the final manuscript.

Long-Term Prognosis of Cognitive Function in Patients With Idiopathic Normal Pressure Hydrocephalus After Shunt Surgery.

The long-term prognosis of cognitive function in patients with idiopathic normal pressure hydrocephalus (iNPH) remains unclear. This study aimed to determine the long-term prognosis of cognitive function in patients with iNPH, as well as the factors related to it. It included 48 patients with iNPH who were treated with cerebrospinal fluid shunting between January 2015 and December 2017 at Osaka Medical College Hospital, with follow-up evaluation of their cognitive function for >2 years. Cognitive function was measured using the Mini-Mental State Examination (MMSE) preoperatively and at 3 months, 1 and 2 years post-operatively. The mean MMSE score (22.4 ± 5.4 preoperatively) improved at 3 months [23.8 ± 5.0 (p = 0.0002)] and 1 year [23.7 ± 4.8 (p = 0.004)] post-operatively. At 2 years post-operatively, they were able to maintain their preoperative level (22.6 ± 5.3). The patients were classified in to the cognitive decline group [11 (23%) patients; a decrease in the MMSE score by ≥ 2 points 2 years after surgery] and the maintenance/improvement group [37 (77%) patients]. Univariate and receiver operating characteristic analyses were performed for the two groups to identify factors associated with cognitive prognosis. In both groups, the patients who were younger (p = 0.009) or had milder symptoms (p = 0.035) had a better long-term prognosis of cognitive function. The cutoffs for age and disease severity (idiopathic normal-pressure hydrocephalus grading scale; INPHGS) were 78 years (area under the curve = 0.77) and 5 points (area under the curve = 0.71), respectively. In conclusion, most patients (77%) were able to improve and maintain cognitive function for at least 2 years after surgery. The fact that disease severity and age are associated with cognitive prognosis suggests that early iNPH intervention is desirable to improve cognitive prognosis.

Prognostic significance of peritoneal cytology in low-risk endometrial cancer: comparison of laparoscopic surgery and laparotomy

BackgroundThere is uncertainty surrounding the prognostic value of peritoneal cytology in low-risk endometrial cancer, especially in laparoscopic surgery. The objective of this retrospective study is to determine the prognostic significance of positive peritoneal cytology among patients with low-risk endometrial cancer and to compare it between laparoscopic surgery and conventional laparotomy.MethodsFrom August 2008 to December 2019, all cases of pathologically confirmed stage IA grade 1 or 2 endometrial cancer were reviewed at Osaka Medical College. Statistical analyses used the Chi-square test and the Kaplan–Meier log rank.ResultsA total of 478 patients were identified: 438 with negative peritoneal cytology (232 who underwent laparotomy and 206 who undertook laparoscopic surgery) and 40 with positive peritoneal cytology (20 who underwent laparotomy and 20 who received laparoscopic surgery). Survival was significantly worse among patients with positive peritoneal cytology compared to patients with negative peritoneal cytology. However, there was no significant difference among patients with negative or positive peritoneal cytology between laparoscopic surgery and laparotomy.ConclusionThis retrospective study suggests that, while peritoneal cytology is an independent risk factor in patients with low-risk endometrial cancer, laparoscopic surgery does not influence the survival outcome when compared to laparotomy.

Association Between Neoadjuvant Chemoradiotherapy and Intractable Serous Ascites After Pancreaticoduodenectomy for Pancreatic Cancer.

Intractable serous (not chylous) ascites (IA) that infrequently develops early following pancreaticoduodenectomy (PD) for pancreatic cancer is a life-threatening problem. The relationship between neoadjuvant chemoradiotherapy (NACRT) for pancreatic cancer and the incidence of IA following PD has not been evaluated. This study aims to identify the risk factors associated with IA that develops early after PD for pancreatic cancer. We retrospectively identified 94 patients who underwent PD for pancreatic cancer at the Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan, from April 2012 to March 2020. Data on 29 parameters were obtained from medical records. Univariate and multivariate analyses were conducted to identify independent risk factors. Levels of serum albumin were compared before and after NACRT to analyze its effect. Survival analysis was also conducted. Of the 92 patients included in this study, 8 (8.70%) were categorized into the IA group. Multivariate analysis identified NACRT [odds ratio (OR) 27, 95% confidence interval (CI) 1.87-394, p = 0.016)] and hypoalbuminemia (≤ 1.6g/dl) just after the operation (OR 50, 95% CI 1.68-1516, p = 0.024) as risk factors. The level of serum albumin was significantly decreased following NACRT. The IA group had poorer prognosis than the control group. IA is a serious problem that aggravates patient's prognosis. Postoperative lymphatic leak might be a trigger of IA. NACRT was a major risk factor, followed by hypoalbuminemia caused by various reasons. These factors may act synergistically and cause IA.

&lt;p&gt;Clinical Features of Japanese Patients with Ocular Inflammation and Their Surgical Procedures Over the Course of 20 Years&lt;/p&gt;

PurposeTo review clinical characteristics of ocular inflammation patients in Osaka, Japan, over 20 years and investigate the efficacy of required surgeries.MethodsWe conducted a retrospective study involving 2730 eyes of 1815 patients with ocular inflammation examined at the Osaka Medical College Hospital from April 1999 to March 2019.ResultsPatients comprised 843 males and 972 females, with a mean age of 56.3 ± 18.5 years. Anterior uveitis, such as scleritis, acute anterior uveitis, and herpes iritis, was the most common anatomical classification (51.2%), followed by panuveitis (37.2%), posterior uveitis (9.4%), and intermediate uveitis (2.2%). Sarcoidosis occurred in 153 patients (8.4%), Vogt-Koyanagi-Harada disease (VKH) in 83 (4.6%), and Behçet’s disease in 68 (3.7%). Sarcoidosis peaked in two age groups: 30s and 50–70s. Of the 1815 patients, 389 eyes of 271 patients (14.9%) had cataract surgery, 162 eyes of 133 (7.3%) had vitrectomy, and 124 eyes of 103 (5.7%) had glaucoma surgery. Among cataract surgery patients, 49 (18.1%) had sarcoidosis, 14 (5.2%) had VKH, and seven (2.6%) had Behçet’s disease, and visual acuity (VA) was improved in 321 eyes (82.5%). Among vitrectomy patients, 15 (11.3%) had acute retinal necrosis, 14 (10.5%) had sarcoidosis, 12 (9.0%) had fungal endophthalmitis, and 11 (8.3%) had malignant lymphoma (ML); 83 eyes (51.2%) needed vitrectomy due to vitreous opacity, and VA improved in 88 eyes (54.3%). Among glaucoma surgery patients, 13 (12.6%) had sarcoidosis, and nine (8.7%) had Posner-Schlossman syndrome.ConclusionAnterior uveitis was the commonest form of uveitis and sarcoidosis was the commonest underlying disease. The age distribution of sarcoidosis was older than in previous reports. 10% of patients with sarcoidosis needed glaucoma surgery, and vitrectomy was required in 50% for vitreous opacity caused by ML or sarcoidosis.

Development of central retinal artery occlusion accompanied by choroidal folds in a patient with antineutrophil cytoplasmic antibody-associated vasculitis

Rationale:We report a case of central retinal artery occlusion (CRAO) accompanied by choroidal folds in a patient positive for myeloperoxidase (MPO)-antineutrophil cytoplasmic antibody (ANCA).Patient concerns:The study involved a 67-year-old female patient who presented at the Department of Ophthalmology, Osaka Medical College, Takatsuki-City, Osaka, Japan on October 24, 2016 after becoming aware of a sudden decrease of visual acuity (VA) in her right eye. Other than suffering with scleritis 6-months previous, there was no obvious past history.Diagnosis:Upon examination, the VA in her right eye was hand motion, and the anterior segment of that eye showed thinning of the superior sclera. Macular edema in the inner retina and cherry red spots were observed in the ocular fundus, and optical coherence tomography (OCT) findings showed hyperreflectivity of the inner retina and choroidal folds. Fluorescein angiography (FA) examination of the fundus showed scattered areas of no retinal perfusion, and indocyanine green angiography (IA) findings of the fundus indicated a possible choroidal circulatory disturbance in her right eye. Blood test findings revealed the patient to be positive for MPO-ANCA. Based on the above findings, the patient was diagnosed with CRAO and choroidal circulatory disturbance due to ANCA-associated vasculitis.Interventions:For treatment, steroid semi-pulse therapy was initiated.Outcomes:Post treatment initiation, the fundus features and choroidal folds gradually improved, and her VA slightly improved to 0.08.Lessons:Based on the FA, IA, and OCT findings, the present case was considered to have CRAO accompanied by choroidal circulatory disturbance due to ANCA-associated vasculitis, a rare disease that may be complicated by choroidal circulatory disturbances.

Validity of the Wide-range Assessment of Vision-related Essential Skills in Japanese Children with Learning Problems.

Our study revealed that the validity of a new Japanese visual-perceptual test was acceptable. Visual-perceptual abilities are important to activities of daily living; thus, accurate assessment of visual perception is especially important for children with neurodevelopmental disorders and particularly so for those with learning problems. Visual perception refers to the process by which one receives visual information through sensory impulses and then translates those impulses into meaning based on a previously developed view of the environment. A problem in Japan is the paucity of visual perception tests that use normative data from children who are native Japanese. The Wide-range Assessment of Vision-related Essential Skills (WAVES), which measures visual perception and eye-hand coordination skills and is based on Japanese normative data, was recently published in Japan. The validity of this test has not been comprehensively established. To investigate the validity of the WAVES, we used the Pearson correlation coefficient to calculate the degrees of association among WAVES scaled and index scores compared with Developmental Test of Visual Perception, Third Edition, scores from 108 elementary school children with symptoms of learning problems. Participants were recruited at Osaka Medical College Learning Disability Center and Sakai Seikeikai Learning Disability Center. The concurrent validity of the WAVES was supported by moderate correlation (r = 0.67, P < .01) between the total scores for visual perception and eye-hand coordination index from the WAVES and general visual perception index from the Developmental Test of Visual Perception, Third Edition, even though a correlation analysis of subtests found differences between the two tests. Our results showed that the indices from the two tests measured nearly the same underlying visual-perceptual constructs and indicated that the WAVES had acceptable levels of concurrent validity.

The impact of additional treatment after endoscopic submucosal dissection for esophageal squamous cell carcinoma in real-world clinical practice.

305 Background: Endoscopic submucosal dissection (ESD) is the standard therapy for the T1a- EP/LPM esophageal squamous cell carcinoma (ESCC), although it is difficult to diagnose the invasion depth accurately before ESD. The incidence of lymph node metastases in ESCC involving the muscularis mucosae (pT1a-MM) and the submucosa (pT1b-SM) is reported to range from approximately 10% to 30%. For the patients with MM, SM or involving LVI or positive vertical margin after ESD, additional treatment (AT) is recommended to prevent local recurrence. However, the AT is not always performed to the frail or elderly patients. The aim of this study is to investigate the outcome of AT and non-AT (NAT) after ESD for ESCC in the real-world clinical practice. Methods: We retrospectively reviewed the ESCC patients who were pathologically confirmed T1a-MM or T1b-SM (UICC-TNM7th) after ESD at Osaka medical college hospital between 2004 and 2016. Results: Among 224 patients who received ESD, 52 patients were pT1a-MM (n = 36; 69.2%) or pT1b-SM (n = 16; 30.8%).Twelve of 52 patients (23%) received AT and forty patients (77%) received NAT. Six patients (AT group: 2 patients, NAT group: 4 patients) had local lymph node recurrence. Five of them underwent salvage therapy. Median follow up time were 54.3 months (range: 48.4-62.4). The 3-, 5-year RFS rate and the 3-, 5-year OS rate were 83.8%[95%CI: 68.2- 92.6], 73.4% [95%CI: 56.0- 85.7] and 94.7% [95%CI: 81.3- 98.6], 91.7% [95%CI: 77.1- 97.3] in all patients, respectively. The 5-year RFS and OS rate were 77.8%, 90.0% in the AT group and 71.6, 92.2% in the NAT group. Conclusions: Although the AT tended to prevent local recurrence, the OS was comparable with NAT because of salvage therapy. The active surveillance is recommended for T1a-MM or T1b-SM ESCC.

Examination of new parameters for sex determination of mandible using Japanese computer tomography data.

In the field of forensic science, sex discrimination of skeletons is an important identification item for personal identification. The individual sex discrimination method using skeletons includes a determination method using measurement values and a macroscopic form observation method. Both methods have advantage and disadvantage. In this study, we used the homologous model technique and principal component (PC) analysis to determine gender difference from morphology of the mandible. 45 patients (23 males and 22 females) of CT imaging for tooth extraction from January 2018 to March 2019 at department of oral surgery, Osaka Medical College. The mean age was 43.1 ± 14.6. Patients with less than 14 remaining teeth were excluded because the number of remaining teeth may affect the shape of the mandible. 3D images were constructed, and 20 landmarks plotting on the 3D model surfaces. We generated template models of the mandible consisting of approximately 8434 polygons. The template model automatically fitted into the individually scanned point cloud of the mandible by minimising external and internal energy functions. As described above, the mandibles were constructed for each sample by using the Homologous Body Modeling software (HBM, Digital Human Technology, Inc.) and the mHBM-Rugle (Medic Engineering Corporation). The mandibles were analysed using the PCA. The contribution of the most important PC was found to be 27.2%. 12 PCs explained over 75% of the total variance. That is, it was able to express 75% or more of the mandible expression with 12 PCs. A significant difference between male and female was observed in the first PCs (Wilcoxon test, p < 0.05). Visualising the result of the first PC showed that the mandibular branch of male was larger than that of female, and the mandible angle was overhanging outside. This method is a combination of the determination method using the previous measurement values and the determination using macroscopic observation, and is considered to be innovative method.