Fukui Red Cross Hospital

We evaluated the prognostic significance and implications of a major pathologic response (MPR) after preoperative treatment for pancreatic ductal adenocarcinoma (PDAC). Preoperative treatment is increasingly used for PDAC to improve oncologic outcomes. The pathologic response represents a potential indicator of treatment efficacy; however, its prognostic value in PDAC remains unclear. We retrospectively analyzed 739 patients who underwent pancreatectomy for PDAC after preoperative treatment at 21 institutions in Japan. The pathologic response was graded using Evans' classification, with MPR defined as Evans grade III/IV. Survival outcomes and prognostic factors were evaluated, and factors associated with achieving MPR were analyzed to develop a predictive model. MPR was achieved in 11.5% of patients. The MPR group had a significantly longer median overall survival (71.5 vs. 40.9mo) and recurrence-free survival (55.5 vs. 15.2mo) than the non-MPR group. Multivariate analysis identified MPR as an independent prognostic factor for overall survival. In the MPR subgroup, neither overall nor recurrence-free survival differed according to adjuvant chemotherapy administration; multivariate analysis did not identify adjuvant therapy as an independent prognostic factor. Predictive factors for achieving MPR included chemoradiotherapy, preoperative duration ≥6 months, normal carbohydrate antigen 19-9 after preoperative treatment, and complete or partial radiologic response. Finally, we developed a simplified predictive model for achieving MPR. MPR was independently associated with favorable survival in PDAC. The prognostic impact of adjuvant chemotherapy was not observed among patients who achieved MPR, suggesting that MPR may inform individualized postoperative management and warrants prospective validation.

The recommendation to discontinue low-dose aspirin (LDA) during the periprocedural period of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) remains controversial in patients at low thrombotic risk. If continuation of LDA does not increase bleeding risk, gastric ESD could be safely performed under sustained antiplatelet effects, benefiting patients. This study aimed to evaluate whether continuation of LDA is noninferior to discontinuation regarding ESD-related bleeding risk in patients with low thrombotic risk. Patients with gastric mucosal neoplasms and low thrombotic risk who were taking LDA were eligible. Participants were randomly assigned to either the discontinuation or continuation group. No prophylaxis was performed except for cauterizing exposed vessels at the ulcer base. The primary end point was the incidence of ESD-related major bleeding. A total of 551 patients were enrolled. In the modified intent-to-treat analysis, the incidence of ESD-related major bleeding (95%) was 7.6% (4.8-11) in the discontinuation group (n = 276) and 10% (6.9-14) in the continuation group (n = 275), yielding a risk difference of 2.5% (-2.3 to 7.4). The upper limit of the 2-sided 90% confidence interval (6.6%) exceeded the predefined noninferiority margin (Δ5%, P = 0.157). The per-protocol analysis supported this negative result, with a risk difference of 4.4% (-0.5 to 9.5). Two patients in the continuation group developed cerebral infarction. The noninferiority of LDA continuation over discontinuation for ESD-related major bleeding in gastric ESD was not demonstrated. Therefore, discontinuation of LDA during the periprocedural period is recommended for patients with low thrombotic risk (UMIN000013177).

A case of tubulointerstitial nephritis and uveitis (TINU) syndrome in a 70-year-old man following administration of the third dose of the mRNA-1273 coronavirus disease 2019 (COVID-19) vaccine is reported. The patient, who had a history of dyslipidemia, developed anorexia two weeks after vaccination. Laboratory evaluation showed marked elevation of serum creatinine from 0.9 to 2.76mg/dL, accompanied by proteinuria and elevated tubular injury markers. Renal biopsy confirmed tubulointerstitial nephritis. Shortly thereafter, he developed bilateral ocular pain, and bilateral uveitis was diagnosed on ophthalmological examination. The combination of renal and ocular findings led to the diagnosis of TINU syndrome. Due to progressive renal impairment, the patient received intravenous methylprednisolone pulse therapy (500mg daily for three days), followed by oral prednisolone (40mg daily), which was gradually tapered. Both renal function and ocular symptoms improved steadily. This case underscores a rare but important potential adverse event following COVID-19 vaccination, highlighting the need for awareness of immune-mediated complications such as TINU syndrome in the post-vaccination setting.

Background/Objectives: Accurate prediction of severe adverse events (SAEs) is crucial for optimizing supportive care while maintaining treatment intensity in diffuse large B-cell lymphoma (DLBCL). We evaluated the predictive value of the Geriatric Nutritional Risk Index (GNRI) for SAEs in de novo DLBCL and examined potential interactions with treatment regimen and age. Methods: This multicenter retrospective study included 555 adults treated with standard immunochemotherapies. SAEs, defined as grade ≥ 3 non-hematological adverse events or febrile neutropenia, were independently assessed by board-certified hematologists. Results: Multivariable logistic regression identified GNRI as an independent predictor of SAEs (odds ratio 0.982, 95% confidence interval 0.967-0.997). Restricted cubic spline modeling revealed a significant non-linear association between GNRI and SAE risk (p = 0.045). No significant interaction was observed between GNRI and regimen or age (p = 0.894 and 0.217, respectively), a finding consistent across subgroups in forest plot analyses. Conclusions: This study showed that lower diagnostic GNRI was independently associated with higher SAE risk regardless of treatment regimen or age. These findings highlight the potential utility of GNRI as a simple clinical indicator for identifying patients at higher risk of treatment-related toxicity, although they are derived from a retrospective, tertiary-care cohort and require confirmation in external prospective studies.

BackgroundThe Nuss procedure is a minimally invasive surgical procedure for treating pectus excavatum. Recently, its application has been extended to flail chest.Case DescriptionA 72-year-old woman presented to the emergency department with ventricular fibrillation caused by acute myocardial infarction. The patient underwent cardiac catheterization and coronary artery stenting following cardiopulmonary resuscitation (CPR). The patient was referred to Fukaya Red Cross Hospital owing to dyspnea caused by a flail chest following CPR. Being an elderly woman, the supporting tissues of the thorax had weakened, and she had a pronounced flail chest, a labored breathing pattern, and severe respiratory distress. Although there is the disadvantage that cardiac massage would become difficult, the cardiologist determined that cardiac function had stabilized after stent placement and that the likelihood of cardiac massage being necessary was extremely low, and therefore it was determined that repair using the Nuss method would be preferable. Two Nuss bars were inserted. Following the procedure, her respiratory condition improved, and she was discharged. Eight months later, the collapse of the anterior chest wall had resolved, and the Nuss bars were removed. However, the patient developed bilateral pneumothoraces post-removal. Thoracic drainage was performed, leading to improvement, and she was subsequently discharged.ConclusionsThis is a rare case of using the Nuss procedure to treat flail chest following CPR. Despite the occurrence of bilateral pneumothorax after Nuss bar removal, the patient’s respiratory condition significantly improved, and she had a favorable prognosis.

The EMPA-REG OUTCOME trial confirmed empagliflozin reduced mortality and heart failure hospitalization risk. These findings raised the possibility that empagliflozin may modulate cardiac autonomic function in patients with type 2 diabetes (T2D). The EMPYREAN study was a prospective randomized open-label assessor-blinded multicenter investigation of patients with T2D without prior antidiabetic therapy with sodium-glucose cotransporter 2 or dipeptidyl peptidase 4 inhibitors. Electrocardiographic monitoring was performed at study onset and after 12 and 24 weeks of treatment. Heart rate variability was analyzed using the MemCalc method. The primary endpoint was the change in the low frequency (LF; 0.04-0.15 Hz)/high frequency (HF; 0.15-0.4 Hz) ratio from baseline to 24 weeks. In all, 113 patients were randomized. The median age in the empagliflozin and sitagliptin groups was 60 and 63 years, respectively. There were no significant differences in serial changes in the LF/HF ratio (0.52, 95% confidence interval [CI] -0.15 to 1.19, P=0.126) or HF (16.13, 95% CI -11.58 to 43.84, P=0.251) between the 2 groups. In time domain analysis, serial changes in root mean square successive difference (1.90, 95% CI -0.56 to 4.38, P=0.12) and percent of difference between adjacent normal RR intervals >50 ms (1.04, 95% CI -0.32 to 2.41, P=0.13) were not significantly different. The effects of empagliflozin and sitagliptin on autonomic nerve activity did not differ significantly in patients with T2D.

症例は61歳，男性．頭部外傷で入院し，開頭術後，寝たきりの状態であった．食事開始後より便秘と腹痛が続いていたが，腹痛増悪と血圧低下が出現した．血液検査で炎症反応の上昇と代謝性アシドーシスを認め，CTでS状結腸遠位側に多発憩室と壁肥厚を認め，同部より口側の結腸は著明に拡張していた．腫瘍による腸閉塞を疑い，減圧目的に下部消化管内視鏡検査を行ったところ，S状結腸憩室炎による狭窄が原因の閉塞性大腸炎の診断となり，緊急手術を施行した．S状結腸遠位側は腫瘤状に硬く短縮し，S状結腸近位側から下行結腸は暗赤色かつ浮腫状であり，まず結腸左半切除を行った．切除断端にびらんや潰瘍を認めたため，結腸右半切除と回腸部分切除を追加し，回腸に単孔式人工肛門を造設した．大腸憩室炎に起因する閉塞性大腸炎は稀であるが，高齢化により左側結腸型の慢性憩室炎が増加しており，閉塞の原因として憩室炎も念頭に置く必要がある．

Nutritional status is an important factor influencing toxicity of treatment. Nutritional assessment indicators such as the Prognostic Nutritional Index (PNI), Controlling Nutritional Status (CONUT) score and modified Glasgow Prognostic Score (mGPS) have been reported to be associated with treatment-related adverse events (AEs) for various malignancies. However, there are no reports investigating the relationship between nutritional status and AEs from poly-(ADP-ribose) polymerase (PARP) inhibitors (PARPi), which are widely used in recent years as maintenance therapy for ovarian cancer. The primary objective was to investigate the usefulness of nutritional assessment indicators in predicting treatment discontinuation due to AEs from PARPi. This multicenter retrospective study included patients diagnosed with ovarian cancer who received maintenance therapy with PARPi from January 2018 to December 2023. PNI, CONUT score, and mGPS were calculated based on hematological parameters measured within 7 days before the start of PARPi therapy. A total of 272 patients received maintenance therapy with PARPi during the period, but due to the absence of the blood collection of albumin levels within one week or other exclusion criteria, 71 patients were finally included in this analysis. AEs were seen in 59 patients (83.1%), including 25 (35.2%) severe events (grade ≥3 in Common Terminology Criteria for Adverse Events v5.0). Eighteen patients (25.4%) discontinued treatment due to PARPi-related AEs. Low PNI (<48.44) and high mGPS (≥1) were predictors of treatment discontinuation in both univariate and multivariate analyses. CONUT was not a significant predictor in this study. Our study suggested that PNI and mGPS can predict the risk of treatment discontinuation due to PARPi-related AEs before starting maintenance therapy. This insight opens avenues for more personalized treatment plans, potentially improving patient outcomes.

Cervical cancer incidence is increasing among Japanese women, which is partly attributed to low screening rates. This study examined the implementation of opt-in human papillomavirus (HPV) self-sampling among Japanese women aged 30-39 years who had not undergone cervical cancer screening, focusing on those requiring preconception care. The responses to the opt-in approach and effectiveness in detecting cervical squamous intraepithelial neoplasia 2 or worse (CIN2+) were evaluated. Participants used the Evalyn® Brush for self-sampling, with HPV testing conducted using the Cobas 4800 system (version 2.2.0). Out of 3489 eligible, unscreened women from four municipalities in Fukui Prefecture, only 10.6% (370/3489) requested the self-sampling kit. Of these, 77.3% (286/370) returned the kit (HPV testing rate: 8.2% (286/3489)). The HPV positivity rate was 13.7% (39/285), yet only 61.5% (24/39) of those with positive HPV results proceeded to cytology testing. Subsequently, three cases of CIN2+ were detected (10.5/1000). While this study demonstrated a reasonable kit return rate and indicated the capability of opt-in HPV self-sampling to detect CIN2+ cases in unscreened women, the low ordering rate of kits and suboptimal compliance for follow-up cytology testing highlight significant challenges. The findings suggest the need for more effective strategies to enhance participation in cervical cancer screening programs.