National Hospital Organization Mito Medical Center

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.

Patient care ownership (PCO) is a critical component of medical professionalism. Although various determinants of PCO among medical residents have been investigated, the impact of workplace social capital (WSC; a social resource concerning employees' perceptions of trust, reciprocity, and network interactions within the workplace) remains unclear. Here, we aimed to examine the association of WSC and PCO. This nationwide cross-sectional study was conducted using an anonymous online survey from January to February 2025. The participants were residents who participated in the General Medicine In-Training Examination. The primary and secondary outcomes were PCO and its four dimensions (i.e. assertiveness, sense of ownership, diligence, and being the "go-to" person), measured using the Japanese version of the PCO Scale, respectively. We adopted WSC and its two dimensions (i.e. horizontal and vertical trust) as the primary and secondary explanatory variables, assessed using the Japanese medical resident version of the WSC Scale, respectively. A total of 2811 residents were analyzed. On multivariable linear regression analysis, WSC total score was positively associated with PCO total score after adjustment for possible confounders. WSC total score was also positively associated with all PCO dimension scores. Additionally, we observed a positive association between each WSC domain score, PCO total score, and each PCO domain score. Our study revealed a significant and consistent association between WSC and PCO. These findings emphasize the importance of fostering a trusting workplace environment, given that PCO constitutes a pivotal component of professionalism and is likely associated with quality patient care.

Multicenter retrospective cohort study. To evaluate the impact of abscess presence and type on treatment duration and clinical outcomes in patients undergoing minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis. Surgical management is increasingly favored for pyogenic spondylitis. Abscesses, particularly epidural and iliopsoas, have been linked to poorer prognoses, and empyema, though uncommon, tends to be particularly severe. However, the effect of specific abscess types on surgical outcomes remains unclear. This study included 92 patients who underwent minimally invasive posterior fixation across 10 centers between 2014 and 2024. Patients were classified into an abscess group (epidural, iliopsoas, empyema, or other) and a non-abscess group. Clinical outcomes, including total duration of intravenous antibiotics and unplanned additional surgeries, were compared. Subgroup and regression analyses were conducted to assess the impact of specific abscess type. Abscesses were present in 65 patients (71%): epidural (n=51), iliopsoas (n=38), and empyema (n=3), with some overlap. Compared with the non-abscess group (n=27; 29%), there were no significant differences in antibiotic duration or rates of unplanned additional surgery. However, iliopsoas abscess was associated with longer antibiotic duration (8.1 weeks vs. 6.6 weeks, p =0.044), while all empyema cases required additional surgery for poor infection control (p =0.000). Regression analysis identified iliopsoas abscess and age ≥65 years as independent predictors of prolonged antibiotic use, whereas epidural abscess was associated with shorter antibiotic duration. Iliopsoas abscesses were associated with longer antibiotic courses, while empyema was linked to poor infection control and a higher likelihood of additional surgery.

Background: Moyamoya syndrome is a moyamoya-like cerebrovascular condition associated with an identifiable underlying condition. Although head trauma has historically been considered a possible contributing factor, it is currently excluded from the Japanese diagnostic criteria. We report a rare case of progressive unilateral moyamoya-like vasculopathy that developed on the ipsilateral chronic subdural hematoma (CSDH) following head trauma, with a decade-long imaging follow-up. Anterior circulation basi-parallel anatomical scanning (BPAS) provided unique insights into the progressive vessel narrowing beyond the vascular lumen, suggesting its potential utility in evaluating such rare vasculopathies. Case Presentation: A 40-year-old man developed a left-sided CSDH after head trauma and underwent burr hole drainage. Although his symptoms resolved, serial magnetic resonance angiography (MRA) over the subsequent 10 years revealed progressive stenosis of the left middle cerebral artery (MCA), ultimately culminating in an occlusion-like appearance. BPAS revealed moyamoya-like collateral vessels in the same hemisphere, a significant reduction in the outer diameter of the left MCA, supporting the presence of structural arterial wall changes that were not apparent on conventional MRA. Single-photon emission computed tomography revealed mildly reduced cerebral blood flow on the affected side, with a difference of less than 5% compared to non-affected side. He remained neurologically non-symptomatic, with no history of transient ischemic attacks or overt ischemic stroke. Conclusions: This case highlights a rare clinical course of progressive ipsilateral moyamoya-like vascular changes following head trauma and burr-hole drainage for CSDH, potentially indicating an association between head trauma, CSDH, and subsequent moyamoya-like collateral vessel development, warranting further investigation. The use of the anterior circulation BPAS contributed to the detection of structural arterial changes that were not apparent on conventional MRA, suggesting its potential utility in evaluating such vascular abnormalities.

This study aimed to investigate the incidence and risk factors of thoracolumbar noncontiguous spinal fractures (NSF) in surgically treated older patients with cervical spine injuries and to evaluate their association with functional outcomes. We retrospectively reviewed 115 patients aged ≥ 65 years who underwent surgery for traumatic cervical spine injuries between 2015 and 2025. Thoracolumbar NSF were defined as fractures located at least two vertebral levels away from the cervical injury. Patient background, comorbidities, laboratory data, and imaging findings were collected. Functional outcome was assessed using the Barthel Index (BI) at discharge, with BI ≥ 60 indicating functional independence. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of NSF and BI ≥ 60. Thoracolumbar NSF were observed in 39.1% of patients. High-energy trauma (odds ratio [OR]: 70.7) and pre-existing vertebral fractures (OR: 12.8) were identified as independent positive predictors, whereas the presence of ossification of the posterior longitudinal ligament was negatively associated with NSF (OR: 0.12). In multivariate analysis for BI ≥ 60, higher serum albumin (OR: 10.7) and lower Charlson Comorbidity Index (OR: 0.46) were associated with better functional outcomes, while spinal cord injury was a negative predictor (OR: 0.17). The presence of thoracolumbar NSF was not associated with functional outcome. Thoracolumbar NSF are relatively common in surgically treated older patients with cervical spine injuries. Although they were not linked to worse functional outcomes, their strong association with high-energy trauma and skeletal fragility highlights the need for comprehensive spinal imaging and early risk assessment.

Understanding renal artery tortuosity is important in urological surgery. The right renal artery normally runs dorsal to the inferior vena cava. In precaval renal artery, vascular anomaly, the right renal artery, branching from the abdominal aorta, runs ventral to the inferior vena cava. Furthermore, the precaval renal artery is often an accessory artery and rarely a single main artery. Preoperative identification of these anomalies is important for successful surgery. Herein, we report a case of 71-year-old woman who visited our department after right renal cancer was detected on computed tomography (CT) performed to investigate the sigmoid colon cancer. Per CT findings, the right renal artery ran ventrally to the inferior vena cava and was the single main artery. The right renal artery abnormality was confirmed preoperatively, and robot-assisted laparoscopic partial nephrectomy (RAPN) was completed without any major intraoperative complications. Approximately 25-40% of the renal arteries are estimated to run abnormally. Among these, the prevalence of a precaval right renal artery is estimated to be 0.8-5.0%, and most are collateral arteries. Furthermore, the precaval right renal artery rarely serves as the single main artery. This report aims to describe a case in which RAPN was performed safely in a patient with a single main artery, the precaval right renal artery, as the course of the right renal artery was known preoperatively.

BackgroundTraditional assessments of clinical competence using multiple-choice questions (MCQs) have limitations in the evaluation of real-world diagnostic abilities. As such, recognizing non-verbal cues, like tachypnea, is crucial for accurate diagnosis and effective patient care.ObjectiveThis study aimed to evaluate how detecting such cues impacts the clinical competence of resident physicians by using a clinical simulation video integrated into the General Medicine In-Training Examination (GM-ITE).MethodsThis multicenter cross-sectional study enrolled first- and second-year resident physicians who participated in the GM-ITE 2022. Participants watched a 5-minute clinical simulation video depicting a patient with acute pulmonary thromboembolism, and subsequently answered diagnostic questions. Propensity score matching was applied to create balanced groups of resident physicians who detected tachypnea (ie, the detection group) and those who did not (ie, the non-detection group). After matching, we compared the GM-ITE scores and the proportion of correct clinical simulation video answers between the two groups. Subgroup analyses assessed the consistency between results.ResultsIn total, 5105 resident physicians were included, from which 959 pairs were identified after the clinical simulation video. Covariates were well balanced between the detection and non-detection groups (standardized mean difference <0.1 for all variables). Post-matching, the detection group achieved significantly higher GM-ITE scores (mean [SD], 47.6 [8.4]) than the non-detection group (mean [SD], 45.7 [8.1]; mean difference, 1.9; 95% CI, 1.1‐2.6; P=.041). The proportion of correct clinical simulation video answers was also significantly higher in the detection group (39.2% vs 3.0%; mean difference, 36.2%; 95% CI, 32.8‐39.4). Subgroup analyses confirmed consistent results across sex, postgraduate years, and age groups.ConclusionsOverall, this study revealed that detecting non-verbal cues like tachypnea significantly affects clinical competence, as evidenced by higher GM-ITE scores among resident physicians. Integrating video-based simulations into traditional MCQ examinations enhances the assessment of diagnostic skills by providing a more comprehensive evaluation of clinical abilities. Thus, recognizing non-verbal cues is crucial for clinical competence. Video-based simulations offer a valuable addition to traditional knowledge assessments by improving the diagnostic skills and preparedness of clinicians.

Background/Objectives: Idiopathic normal-pressure hydrocephalus (iNPH) is a potentially reversible neurological disorder characterized by gait disturbance, cognitive impairment, and urinary incontinence. Its pathophysiology involves impaired cerebrospinal fluid (CSF) absorption, and recent research has highlighted the role of the glymphatic and meningeal lymphatic systems in this process. However, the factors that trigger the clinical manifestations of iNPH in subclinical cases remain poorly understood. Case Presentation: Herein, we report two rare cases of iNPH in which clinical symptoms only became apparent following systemic infections. An 82-year-old man presented with transient neurological deficits during a course of sepsis caused by Klebsiella pneumoniae. Neuroimaging revealed periventricular changes and mild ventricular enlargement. Shunting and a tap test led to significant improvements to both his gait and cognition. An 80-year-old man with a history of progressive gait disturbance and cognitive decline developed worsening urinary incontinence and acute cerebral infarction caused by Staphylococcus haemolyticus bacteremia. Magnetic resonance imaging revealed a ventriculomegaly with features of disproportionally enlarged subarachnoid space hydrocephalus and a corona radiata infarct. Clinical improvement was achieved after a ventriculoperitoneal shunt was placed. Conclusions: Our two present cases suggest that systemic inflammatory states may act as catalysts for the manifestation of iNPH in patients with predisposing cerebral ischemia or subclinical abnormalities in CSF flow, highlighting the need for higher clinical awareness of iNPH in older patients who present with neurological deterioration during systemic infections. Early diagnosis and timely shunting after appropriate infection control may facilitate significant functional recovery in such patients.