Hiroshima General Hospital

Disease duration of urticaria is variable from days to decades. However, the mechanism of persistence for urticaria is largely unknown. To investigate factors which relate to the prognosis of urticaria, we conducted a cross-sectional analysis on disease durations of 1061 patients with urticaria who visited nine primary dermatology clinics from 1st October to 11th November 2020. Among them, 216 (20.4%) had acute urticaria, while 383 (36.1%) and 125 (11.8%) had suffered from urticaria for 3 years or more and for 10 years or more, respectively. There was no significant difference between males and females in disease duration. In patients under 20 years old, 75 (38.9%) had acute urticaria. By contrast, more than 20% of patients older than 50 years had urticaria for 10 years or more. Disease duration for 3 years or more of patients with dermographism and those with cholinergic urticaria was 42% and 45.3%, respectively. Although a majority of urticaria likely remit, more than one-third of patients at primary dermatology clinics suffer from urticaria for 3 years or longer. The disease duration was longer in older patients, those with dermographism and/or cholinergic urticaria.

Recent studies have demonstrated that breast pathological complete response (pCR) can be accurately diagnosed preoperatively using image-guided needle biopsy after neoadjuvant chemotherapy (NAC), underscoring the value of incorporating ypT stage into prediction models for axillary response (ypN0). Based on this evidence, we developed and externally validated a nomogram to predict ypN0 in patients with clinically node-positive (cN+) breast cancer treated with NAC. This retrospective, multicenter study included 609 patients with cN + breast cancer who underwent NAC followed by surgery. A nomogram was developed using a training cohort (n = 330) and validated in an independent cohort (n = 279). Diagnostic performance was evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots, decision curve analysis (DCA), and positive predictive value (PPV). The nomogram incorporated five predictors: ypT stage, cN stage, hormone receptor status, HER2 status, and post-NAC cN stage. It showed strong discriminative ability, with bias-corrected AUCs of 0.858 in the training cohort and 0.855 in the validation cohort. Calibration and DCA confirmed good model performance. PPV exceeded 0.90 when the nomogram-predicted probability was ≥ 0.7 in both cohorts. This nomogram demonstrated high diagnostic accuracy for predicting ypN0 and may support the selection of candidates for axillary surgery de-escalation based on post-NAC biopsy findings. Prospective validation using biopsy-confirmed pCR is warranted.

BackgroundThe incidence of incorrect nasogastric tube (NGT) insertion into the trachea or distal airways is approximately 2%. When an NGT penetrates the visceral pleura and enteral feeding products are inadvertently administered into the lungs or thoracic cavity, severe chemical pneumonia and empyema can develop. Thus, confirming the NGT placement site before initiating feeding is crucial. Chest radiography (CXR) remains the gold standard for confirming NGT placement. However, enteral feeding products are often administered without prior CXR, leading to complications. This report describes two cases of iatrogenic empyema caused by incorrect placement of NGT in the thoracic cavity.Case DescriptionCase 1 was a 70-year-old man with a history of cerebral hemorrhage sequelae who was receiving NGT feeding. Routine NGT replacement was performed without CXR. Dyspnea developed following the administration of an enteral feeding product. Emergency CXR revealed incorrect NGT placement in the right thoracic cavity. The patient’s circulation was stable, and he was managed with chest drainage. Case 2 involved a 95-year-old woman who was debilitated due to advanced age and was receiving NGT feeding. Routine NGT replacement was performed without CXR. Subsequently, she developed dyspnea and hypotension after the administration of an enteral feeding product. Emergency CXR and computed tomography revealed NGT placement in the right thoracic cavity, accompanied by a right pneumothorax and pleural effusion. As the patient was in shock, emergency surgery was performed following chest drainage. Both patients recovered successfully.ConclusionsIatrogenic empyema induced by NGT feeding is a severe complication often resulting in respiratory failure. Prompt management with chest drainage is critical, and emergency surgery should be considered in cases of circulatory failure. To prevent such events, accurate evaluation of NGT placement via CXR before commencing feeding is imperative. Additionally, the indications for NGT insertion should be carefully assessed on a case-by-case basis.

Drug-related cardiomyopathy, most notably that caused by anthracyclines, significantly impairs the quality of life in childhood cancer survivors (CCS). In contrast to adults, early-onset chronic cardiomyopathy following chemotherapy is relatively uncommon in CCS, and the underlying pathophysiological mechanisms remain poorly understood. We present a case of a nine-year-old boy who developed severe acute heart failure and subsequent cardioembolic stroke due to early-onset anthracycline-induced cardiotoxicity following treatment for Ewing sarcoma. Whole-exome sequencing revealed two candidate single-nucleotide polymorphisms: HAS3 rs2232228 and RAC2 rs13058338, which may be implicated in the genetic predisposition to anthracycline-related cardiomyopathy. This case highlights the importance of considering early-onset cardiotoxicity in pediatric patients and supports further research into genetic risk-based screening and prevention strategies.

Elevated serum IgG4 is a key diagnostic marker for type 1 autoimmune pancreatitis (AIP), but some patients lack IgG4 elevation, complicating diagnosis. This study investigated the clinicopathological features of AIP without elevated serum IgG4 levels. A total of 323 patients diagnosed with AIP at Hiroshima University Hospital and affiliated institutions were analyzed. Patients were categorized into IgG4-positive (≥ 135 mg/dL), IgG4-negative (< 135 mg/dL with “definite” or “probable” diagnosis), and possible (with “possible” diagnosis) groups. Comparative analysis was performed between the IgG4-positive (n = 281) and IgG4-negative (n = 20) groups. Segmental or focal narrowing of the main pancreatic duct (MPD) and retroperitoneal fibrosis were significantly more common in the IgG4-negative group (90.0% vs. 58.7%, P = 0.011; and 35.0% vs. 12.5%, P = 0.012, respectively). Although the number of pathological findings was comparable, the rate of surgical intervention was significantly higher in the IgG4-negative group (P < 0.001). No significant differences were observed in relapse rates or relapse sites between the two groups. These findings suggest that MPD narrowing and retroperitoneal fibrosis may be characteristic of AIP without elevated IgG4. Vigilant monitoring for relapse is warranted, regardless of serum IgG4 levels.

Objective: The prevalence of acute hepatic porphyria (AHP) in Japan is unknown. To diagnose AHP, identifying populations with a high prevalence of AHP is essential. We focused on non-specific abdominal pain (NSAP); however, the criteria for NSAP vary across studies. Therefore, this study aimed to investigate the diagnostic process of undiagnosed abdominal pain in general medicine clinical practice before proposing a definition of NSAP. In addition, we aimed to examine the potential AHP-related symptoms and implementation of AHP testing in these patients. AHP is a rare but fatal and treatable disease; hence, its early diagnosis is essential.Design: This retrospective observational study was conducted in the general medicine departments of six medical institutions in Japan over a 3-year period beginning on April 1, 2019.Participants: Patients with abdominal pain who underwent abdominal imaging examinations were included.Main outcome measures: The primary outcome was to characterize patients with undiagnosed abdominal pain. In addition, this study aimed to identify situations where physicians attempt to diagnose AHP in patients with abdominal pain.Results: Of the 1915 eligible participants, 317 (16.6%) had undiagnosed abdominal pain, and none of them were diagnosed with AHP in diagnosed abdominal pain. The median patient age was 55 years, and 134 patients were male. Multivariate logistic analysis revealed that hospitalization, dull pain, and the absence of depressive symptoms were associated with abdominal pain. All patients with undiagnosed abdominal pain demonstrated two to four indicative symptoms of AHP. However, none underwent urinalysis for a definitive diagnosis of AHP.Conclusions: Depressive symptoms and the absence of dull pain were associated with undiagnosed abdominal pain. Hospitalization for examination contributed to improving the diagnosis of abdominal pain. Despite the presence of indicative symptoms, urinary markers for AHP diagnosis were not measured. Establishing a diagnostic strategy for undiagnosed abdominal pain would provide better opportunities for patients with NSAP and could help shorten the diagnostic journey for those with rare diseases such as AHP.

Background: Reduced or delayed access to medical resources on weekends could lead to worsening outcomes, in critically ill infected patients requiring intensive care unit (ICU) admission. Objective: To investigate the “weekend effect,” on critically ill infected patients in Japanese ICUs for the first time. Design: Multicenter retrospective cohort study. Methods: We examined data from Japanese ICU patients participating in the DIANA study, a multicenter international observational cohort study. This prospective investigation enrolled critically ill patients with infections admitted to the ICU. The primary endpoint was successful discharge from the ICU within 28 days of admission. Outcome measures were evaluated through both univariate and covariate Cox regression analyses, providing hazard ratios (HRs) along with estimated 95% confidence intervals (CIs). Results: Out of the 276 patients enrolled in the DIANA study across 31 facilities, 208 patients (75.4%) meeting the inclusion criteria were included in the analysis. The weekday ICU admission group comprised 156 patients (75.0%), while the weekend ICU admission group comprised 52 patients (25.0%). In the multivariate Cox regression analysis, there were no statistically significant differences observed in the rates of ICU discharge alive within 28 days and 14 days (28 days, HR: 0.94, 95% CI: 0.63–1.40; 14 days, HR: 0.97, 95% CI: 0.64–1.48). Furthermore, the overall ICU mortality rates at 28 days and 14 days after ICU admission did not show statistical significance between patients admitted on weekends and those admitted on weekdays (ICU mortality, 28 days: 13.5% vs 11.5%, p = 0.806; 14 days: 7.7% vs 10.9%, p = 0.604). Conclusion: The rates of ICU discharge alive within 28 days after ICU admission did not differ significantly between weekday and weekend admissions, both in the unadjusted and adjusted analyses. Moreover, further well-designed studies are warranted to thoroughly assess this effect.

Streptococcal toxic shock syndrome (STSS) is a life-threatening condition characterized by a sudden onset and rapid progression to multiple organ failure. The pathogen involved is Group A streptococcus (GAS). We report two cases of STSS that developed following post-traumatic cellulitis in elderly individuals residing in an assisted living facility. The first case involved a 93-year-old male. He developed cellulitis in his right leg after a fall, which rapidly progressed to multiple organ failure. Despite antibiotic therapy, he succumbed to the infection within 30 hours of admission. Blood culture detected GAS. The second case was a 72-year-old man. He developed cellulitis after falling and hitting his leg. He initially received oral antibiotics for cellulitis, but his condition worsened rapidly, requiring emergency amputation and intensive care. Although he temporarily recovered, he later developed severe pneumonia and passed away. A culture of necrotic tissue obtained during surgery confirmed the presence of GAS. STSS is an invasive infection with a high mortality rate, often triggered by minor skin injuries. Although STSS following minor trauma has not been previously reported, our findings suggest that even minor wounds from falls can serve as an entry point for GAS, leading to severe infection. Given the increasing prevalence of STSS in Japan, healthcare providers, particularly in facilities caring for elderly individuals, should maintain a high index of suspicion for early detection and intervention. We present two cases of STSS following post-traumatic cellulitis. With the rising incidence of STSS in Japan, early recognition and prompt treatment are crucial in all healthcare settings to improve patient outcomes.