Chiba Rosai Hospital

Morbidity and mortality rates after surgery in patients with perforated peptic ulcer (PPU) remain high. Although several scoring systems have been proposed, only a few machine learning models have been designed to predict postoperative adverse events. This study aimed to develop and deploy a predictive model for the risk of postoperative adverse events in patients with PPU. We analyzed data from the Perforated Peptic Ulcer Analyzing Project, which is a retrospective survey of adult patients with PPU in seven participating institutions in Japan between January 2011 and December 2022. The postoperative adverse events were defined as complications with a Clavien-Dindo classification of Grade III or higher. The variables were selected based on permutation feature importance derived from a random forest algorithm using bootstrap sampling. Internal-external cross-validation was conducted to develop and evaluate the model's performance. The final model was deployed as an interactive web application. Of the 702 potentially eligible patients, 425 were treated surgically. Of these, 78 patients (18.3%) experienced postoperative adverse events. Ten variables were selected and used to develop a random forest model that displayed favorable discriminatory ability, with a pooled area under the receiver operating characteristic curve (AUROC) of 0.83. Compared to the other systems, the random forest model outperformed the PULP (AUROC, 0.79) and Boey scores (AUROC, 0.67). In this study, a machine learning model was developed and deployed to predict postoperative adverse events in patients with PPU. Further external validation is required for clinical use.

Evidence regarding the effectiveness of mesenchymal stem cells in improving hip function in patients with hip osteoarthritis (OA) remains inconsistent. Therefore, we aimed to estimate the longitudinal trajectories of treatment effects in individuals with hip OA following intra-articular administration of autologous adipose-derived stem cells (ASCs), both in the overall cohort and the cohort stratified by OA severity, and to explore the prognostic factors of treatment outcomes. This retrospective study included adults with hip OA who underwent magnetic resonance imaging (MRI) before treatment between 2020 and 2023. All patients underwent intra-articular ASC administration. The primary outcomes were the total scores on the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) at 1, 3, and 6 months after treatment. A linear mixed-effects model was used to estimate the marginally predicted JHEQ total score changes over time for all patients and compare these changes among subgroups categorized according to OA severity. Furthermore, models that included MRI findings were used to explore potential prognostic factors. We identified 168 hips in 129 patients. In the analysis of all patients, the JHEQ total scores significantly increased at 1, 3, and 6 months after treatment compared with baseline. In the mixed-effects analysis, the predicted change in the JHEQ total score from the baseline to the 6-month follow-up was 10.6 points (95% confidence interval, 8.3 to 12.8), with an increasing trend over time. The effect modification by OA severity on the JHEQ total score was observed over time after treatment (P=0.016). Prognostic analysis revealed that patients with moderate hip OA had higher JHEQ total scores after treatment than those with mild hip OA (P=0.028). Additionally, female patients had higher JHEQ total scores after treatment than male patients (P=0.025). The presence of ligamentum teres abnormalities was associated with low JHEQ total scores after treatment (P=0.011). Intra-articular ASC treatment enhanced patient-reported outcomes over 6 months, with differences observed across hip OA severities. Female sex and moderate hip OA were positive prognostic factors, whereas ligamentum teres abnormalities were negative prognostic factors for patient-reported outcomes after ASC treatment. These findings can be used to inform patients and clinicians about the expected course of treatment and aid clinical decision-making regarding the use of intra-articular ASC treatment for hip OA.

This study aimed to determine the association between the baseline magnetic resonance imaging (MRI) findings and clinical outcomes after articular injection of adipose-derived mesenchymal stem cells (ASCs) for knee osteoarthritis (KOA). This retrospective study included 149 patients with varus-type KOA treated with a single intraarticular ASC injection. All patients underwent a MRI evaluation before treatment. Patients were categorized following the MRI Osteoarthritis Knee Score (MOAKS) system cartilage score into the mild, moderate, or severe KOA groups. Additionally, joint effusion and synovitis, bone marrow lesions (BMLs), and meniscal extrusions were graded with the MOAKS. Knee Osteoarthritis Outcome Score (KOOS) was obtained at baseline, 1-, 3-, 6-, and 12-month posttreatment. The responder rate in the Outcome Measures in Arthritis Clinical Trials-Osteoarthritis Research Society International was assessed with the KOOS. Multivariate logistic regression analyses were conducted to determine factors associated with the responder rate. All KOOS subscales significantly enhanced with the greatest improvement from baseline to6months which plateaued between 6 and 12 months. The responder rate was 65.4% in the mild/moderate KOA compared to 35.2% in the severe KOA at 12 months. Lower OA grade (odds ratio [OR]:0.52; 95% confidence interval (CI): 0.31-0.88; P=0.015), smaller BMLs in medial femoral condyle(OR:0.36; 95% CI: 0.14-0.94; P=0.037), and less meniscal extrusion (OR: 0.31; 95% CI: 0.11-0.89;P=0.029) were associated with higher responder rate at 6 months in multivariable logisticregression analysis. The factors associated with higher responder rate at 12 months included lower OA grade (OR: 0.42; 95% CI: 0.25-0.73; P=0.002) and younger age (OR: 1.04; 95% CI: 1.00-1.08; P=0.042). ASC treatment for KOA enhanced short-term clinical outcomes. MRI findings, including cartilage lesions, BMLs, and meniscal extrusion, were associated with responder rate, helping physicians identify which patients may benefit from this therapy.

当科で2021年１月から2024年３月まで末梢性顔面神経麻痺の予後診断としてENoG（Electroneurography）を施行した症例で経過が追えた22例に対してENoG値と治癒までの期間の関係について検討した．また，初診時の耳痛，アブミ骨筋反射（stapedial reflex：SR）の有無，高血圧症，糖尿病合併の有無がENoG値，治癒までの期間に与える影響について検討した．耳痛，SRの有無，高血圧症，糖尿病合併の有無とENoG値（％）の平均，治癒までの期間（日数）の平均との関係に統計学的に有意差は認めなかった．またENoG値と治癒までの期間との間には統計学上有意な相関が認められた（r=－0.47197, n=22, p=0.0255）．今回の検討では，ENoGで20％以上であれば発症から２ヵ月を目安に回復することが分かった．

要旨 症例は20歳代の女性。鈍的腹部外傷にて当院へ救急搬送された。腹部造影CT検査にて，外傷性十二指腸損傷と第1腰椎破裂骨折を認めたため，外傷性十二指腸損傷に対して同日緊急手術を施行した。十二指腸水平部の後壁に2cm円大の穿孔部を認め，単純閉鎖と大網被覆を施行した。また，損傷部の減圧と食物の流入を防ぐため，幽門輪のすぐ肛門側で胃と十二指腸を離断し，胃空腸吻合による十二指腸憩室化を同時に施行した。術後3日目に術後出血で，開腹止血術を施行した。術後14日目に第1腰椎破裂骨折に対して後方固定術を施行した。その後は，遺残膿瘍に対してドレナージ管理を続け，術後77日目に自宅退院となった。

Figures are essential components of case reports, often conveying information more effectively than the text. Common figure types include images, pathology slides, photographs, schematic drawings, and clinical courses. Each figure type should follow four design principles: alignment, repetition, proximity, and contrast. Precise "alignment" of elements and "repetition" with font usage are crucial for improving clarity. Employing "contrast," such as arrows to highlight specific areas, can also significantly improve visual impact. Additionally, enlarged views or detailed schematics can be beneficial in certain cases. Creating figures early in the process can boost your motivation to write case reports. The enjoyment of writing case reports lies in discovering the key learning points of the case and summarising them. Additionally, creating figures for your case can be enjoyable.

BackgroundMultiple system atrophy (MSA) is a progressive, incurable, life-threatening neurodegenerative disease uniquely characterized by the risk of sudden death, which makes diagnosis delivery challenging for neurologists. Empirical studies on breaking a diagnosis of MSA are scarce, with no guidelines currently established. This study aimed to investigate neurologists’ current practices and experiences in delivering the diagnosis of MSA.MethodsWe conducted a multicenter online survey and employed a mixed-methods (quantitative and qualitative) study design in which responses to open-ended questions were analyzed qualitatively using critical incident technique.ResultsAmong the 194 neurologists surveyed, 166 opened the survey (response rate = 85.6%), of whom 144 respondents across various Japanese regions completed the survey. Accordingly, 92.3% and 82.8% of the participating neurologists perceived delivering the diagnosis of MSA and explaining the risk of sudden death as difficult, respectively. Factors independently associated with difficulties in diagnosis delivery included explaining the importance of the family decision making process in life-prolonging treatment, perceived difficulties in delivering information regarding the risk of sudden death, and perceived difficulties in differential diagnosis of MSA.ConclusionsOur findings showed that the majority of neurologists perceived delivering the diagnosis of MSA and explaining the risk of sudden death as difficult, which could have been associated with the difficulty of breaking the diagnosis of MSA. Difficulty in conveying bad news in MSA are caused by various factors, such as empathic burden on neurologists caused by the progressive and incurable nature of MSA, the need to explain complex and important details, including the importance of the family decision-making process in life-prolonging treatment, difficulty of MSA diagnosis, and communication barriers posed by mental status and cognitive impairment in patients or their family members. Neurologists consider various factors in explaining the risk of sudden death (e.g., patient’s personality, mental state, and degree of acceptance and understanding) and adjust their manner of communication, such as limiting their communication on such matters or avoiding the use of the term “sudden death” in the early stages of the disease. Although neurologists endeavor to meet the basic standards of good practice, there is room for the multiple aspects for improvement.

Plexiform neurofibromas (PNs) occur in approximately 50% of patients with neurofibromatosis type 1 (NF1). PNs are rare in the abdominal cavity and especially rare in hepatobiliary lesions. A 31-year-old man with NF1 had a tumor extending along the celiac artery, superior mesenteric artery, and intrahepatic portal vein. We diagnosed him with diffuse PN based on liver tumor biopsy findings and the tumor form. Because the tumor had invaded along the intrahepatic portal vein, surgical resection was deemed difficult, and the patient was followed up with imaging studies. The patient remained asymptomatic without tumor growth.