Hikone Central Hospital

Nasal vaccines characterized by secretory IgA (SIgA) induction are effective in preventing mucosal infection. SIgA induction is potentiated by mucosal adjuvants, and the exploration of new safe and effective candidates is important. Nanosized hydroxyapatites (HAs) have the potential to enhance immune responses. The membrane vesicles (MVs) released from Streptococcus mutans UA159, a cariogenic bacterium, contain immunogenic glucosyltransferases (GTFs). We evaluated HAs made from eggshell waste, including nanosized particles, as a mucosal adjuvant against nasally administered MVs. Scanning electron microscopy revealed that the MVs were adsorbed to the eggshell-derived HA surface, and these complexes formed various sizes of aggregates. The coadministration of eggshell-derived HAs reinforced the MV-specific mucosal IgA and systemic IgG response, with levels nearly to those induced by the coadministration of polyriboinosinic polyribocytidylic acid, known as a mucosal adjuvant. MV-only immunization also induced MV-specific antibody responses, although the levels were lower. Immunization with MVs with or without eggshell-derived HAs induced IFN-γ/IL-17 secretion. Biofilm formation by the S. mutans UA159 gtfBgtfC double-deficient strain with wild-type-derived MVs containing GTF-B and GTF-C was inhibited by the induced IgGs via MV neutralization. These results suggest that eggshell-derived HAs are potentially effective mucosal adjuvants against S. mutans MVs coadministered nasally.

Small cell carcinoma of the bladder (SCCB) is a rare and aggressive disease with no established standard treatment. We report a case of SCCB that initially progressed with chemotherapy but responded well to a combination of chemotherapy and radiotherapy. A 62-year-old man presented with painless gross hematuria. Transurethral resection of the bladder tumor (TURBT) confirmed SCCB. Gemcitabine-carboplatin (GEM-CBDCA) and pembrolizumab were ineffective, leading to rapid tumor progression. The patient developed bladder tamponade and obstructive renal failure. Emergency radiotherapy (30 Gy) controlled bleeding, and etoposide-carboplatin chemotherapy resulted in significant tumor shrinkage. This case highlights the potential effectiveness of etoposide-carboplatin and radiotherapy in SCCB, especially in cases resistant to other treatments. Further studies are needed to establish optimal treatment strategies for SCCB.

Far-out syndrome is often related to lumbosacral transitional vertebrae (LSTV) and can result in L5 radiculopathy. Although conservative treatment can resolve the radiculopathy, surgical treatment should be considered when the symptoms are refractory. Several surgical procedures, including facetectomy with fusion surgery and nerve root decompression via the anterior or posterior approach, have been described. However, research regarding the efficacy of oblique lumbar intervertebral fusion at L5/S1 (OLIF51) to resolve far-out syndrome is limited. This case report aimed to report the efficacy of this surgery. OLIF51 was performed for two patients with far-out syndrome. The first patient (an 81-year-old man) had undergone posterior lumbar intervertebral fixation from L3 to L5 for degenerative lumbar spondylosis. The right refractory L5 radiculopathy persisted after surgery. As the L5 radiculopathy might have resulted from LSTV, posterior nerve decompression surgery was performed. However, the symptoms recurred after one month, and OLIF51 was performed to decompress the L5 nerve root in the anterior exit zone. The second patient (a 46-year-old man) had a disc herniation at L4/5, which was treated surgically five months prior. Because the right L5 radiculopathy related to LSTV persisted, OLIF51 was performed. Following OLIF51, the L5 nerve root radiculopathy disappeared in both cases. Both patients have been followed up at the outpatient clinic, and their symptoms have not recurred for 12 and 10 months in the first and second patients, respectively. OLIF51 can effectively resolve far-out syndrome related to LSTV.

症例は36歳の女性で，手術歴はないが31歳時に腸閉塞を発症し保存的加療にて軽快した既往があった．腹痛を主訴に前医受診し，単純CTでS状結腸軸捻転の疑いあり，加療目的に当科紹介受診となった．腹痛は中程度であるも継続しており，腹部造影CTを施行した．十二指腸水平脚は認めず，小腸は右側を走行し大腸は左側に分布する位置関係で，SMV rotation signと盲腸～上行結腸が捻転する所見であった．腸回転異常症を原因とする中腸軸捻症と診断し，腹腔鏡下腸閉塞解除術を施行した．腹腔鏡観察したところ回盲部を主体とした捻転を認め，捻転解除，癒着靱帯の切離，予防的虫垂切除を施行した．術後経過は順調で術後6日目に退院となった．成人腸回転異常症に伴う中腸軸捻症に対する腹腔鏡手術は緊急手術においても適切に施行することができ，手術治療法として有用と考えられるため，症例経験を報告する．

The phenomenon of sex chromosome loss from hematopoietic cells is an emerging indicator of biological aging. While many methods to detect this loss have been developed, enhancing the field, these existing methods often suffer from being labor-intensive, expensive, and not sufficiently sensitive. To bridge this gap, a novel and more efficient technique is developed, named the SinChro assay. This method employs multiplexed single-cell droplet PCR, designed to detect cells with sex chromosome loss at single-cell resolution. Through the SinChro assay, the age-dependent increase in Y chromosome loss in male blood is successfully mapped. The age-dependent loss of the X chromosome in female blood is also identified, a finding that has been challenging with existing methods. The advent of the SinChro assay marks a significant breakthrough in the study of age-related sex mosaicism. Its utility extends beyond blood analysis, applicable to a variety of tissues, and it holds the potential to deepen the understanding of biological aging and related diseases.

Transforaminal full-endoscopic surgery can be performed under local anesthesia, which is safer than general anesthesia, especially in the elderly. However, emergencies can still occur under local anesthesia. We describe a case of cardiac arrest at the start of full-endoscopic spine surgery under local anesthesia. The patient was an 80-year-old woman with right lower leg pain caused by two-level lumbar spinal canal stenosis. Two-stage full-endoscopic spine surgery under local anesthesia was planned. The first surgery was completed uneventfully. However, during the second surgery, cardiac arrest occurred because of Mobitz type II atrioventricular block. Percutaneous pacing was started immediately, followed by insertion of a temporary pacemaker via the femoral artery as a life-saving measure. Four days later, a permanent pacemaker was implanted. One month later, the second-stage decompression was completed without complications. Elderly patients require careful intraoperative monitoring for emergencies during surgery under local anesthesia as under general anesthesia. J. Med. Invest. 71 : 314-319, August, 2024.

Bone wax is a flexible hemostatic agent commonly used for surgery in the posterior cranial fossa to control bleeding from the mastoid emissary vein. A large amount of bone wax can migrate into the sigmoid sinus through the mastoid emissary canal (MEC). We aimed to identify clinical factors related to intraoperative bone wax migration through the MEC during microvascular decompression (MVD) surgery, which may result in sigmoid sinus thrombosis. We retrospectively collected the clinical data of patients with trigeminal neuralgia, hemifacial spasm, or trigeminal neuralgia accompanied by painful tic convulsif who underwent MVD. Basic information and the residual width and length (from the bone surface to the sigmoid sinus) of the MEC on computed tomography images were collected. We compared the collected clinical data between 2 groups of cases with and without intraoperative bone wax migration in the sigmoid sinus. Fifty-four cases with intraoperative bone wax migration and 187 patients without migration were enrolled. The t -test revealed significant differences in the width and length of the MEC ( P = .013 and P = .003, respectively). These variables were identified as significant factors in predicting intraoperative bone wax migration using multivariate logistic regression analysis. The large size of the MEC may be related to intraoperative bone wax migration into the sigmoid sinus in MVD. Neurosurgeons should be aware of these risks. Bone wax should be applied appropriately and hemostasis should be considered to control bleeding from the mastoid emissary vein in patients with a large MEC.

We investigated the effects of door-to-tolvaptan (D2T) time on short-term urine volume and in-hospital clinical outcomes in patients with acute heart failure (AHF). Patients with AHF, treated with tolvaptan at two hospitals, were enrolled in this retrospective observational study. The D2T time was defined as the time elapsed from the arrival of a patient at a participating hospital to the first administration of tolvaptan. The group with the D2T time within 6h was defined as the 'early group'. The primary outcome was 48-h urine volume. The secondary outcomes were in-hospital death, length of hospital stay, and worsening renal function (WRF) incidence. A restricted cubic spline model was used to evaluate the presence of a nonlinear association between the D2T time and 48-h urine volume and the odds ratio of WRF incidence. Our study included a total of 138 patients with AHF who were started on tolvaptan after hospitalization. The median D2T time was 5.3h (interquartile range: 3.0-31.9h). Seventy-four patients (53.6%) were classified to be in the early group. Baseline characteristics were similar in the two groups: mean age (85.4±9.6years vs. 84.5±9.5years; P=0.59) and male sex (n=22 [33.3%] vs. n=29 [46%]; P=0.16), except that patients in the early group had higher systolic blood pressure than those in the delayed group (138.2±22.9 vs. 125.7±21.7; P=0.001). The initial tolvaptan dose in the delayed group was much lower than that in the early group (7.5 [7.5, 7.5] vs. 7.5 [5.6, 7.5] mg; P=0.01). Total urine volume in 48h did not differ in the early and delayed groups (4113±1758mL vs. 4201±1893mL; P=0.80). The relationship between D2T time and total urine volume within 48h increased slightly, with a peak at a D2T time of 15h, and gradually decreased, thereafter. In-hospital death and the length of hospital stay did not differ significantly between the two groups (n=1, 1.3% vs. n=4, 6.3%; P=0.18, and 5.0 [12.0, 30.0] vs. 22.0 [14.5, 30.0] days; P=0.17, respectively). Notably, the restricted cubic spline model for the odds ratio of WRF incidence increased as the D2T time was delayed (P for effect<0.01). The shorter D2T time did not affect the short-term urine volume and in-hospital outcomes but reduced the risk of WRF incidence in patients with AHF.

Background: Asymptomatic cervical dumbbell-type tumors can be incidentally diagnosed. Notably, the chronological changes in the size of these tumors have not been satisfactorily described.Case Description: A 57-year-old man was clinically followed for an asymptomatic cervical dumbbell-type tumor that had the appearance of a schwannoma on magnetic resonance (MR) images obtained over a 7-year period. Notably, the tumor compressed both the spinal cord and the right vertebral artery. At the end of the 7-year period, the patient sustained a cerebral infarction due to atherosclerosis of the right vertebral artery; the angiogram revealed both atherosclerosis and the tumor compressing the right vertebral artery. After the stroke/ischemic event, the tumor progressively shrunk on MR images obtained for the following 4 years, and the spinal cord compression was similarly relieved.Conclusion: Here, we report on a 57-year-old man with cervical MR images revealing that a cervical dumbbell schwannoma was progressively compressing both the spinal cord and the right vertebral artery. However, following a cerebral infarction, the tumor underwent spontaneous shrinkage over the next 4 years, thus relieving the compression.