Niigata City General Hospital

Total gastrectomy (TG) is commonly performed as the standard treatment for upper third advanced gastric cancer (AGC). Proximal gastrectomy (PG) may be a potential alternative procedure for upper-third AGC. However, its oncologic safety remains uncertain. This study aimed to compare the long-term outcomes of PG and TG for upper-third AGC and to evaluate the oncological safety of PG. We retrospectively analyzed the data of patients who underwent PG or TG for clinical T2-T4aNanyM0 upper-third gastric cancer at six institutions between 2018 and 2022. To minimize selection bias, propensity score matching (PSM) was performed at a 1:1 ratio. The primary endpoint was overall survival (OS). A total of 208 patients with upper-third AGC were included. After PSM, 104 patients were selected for analysis, with 52 patients in each group. The 3-year OS rates were 81.8% in the PG group and 70.8% in the TG group, with no statistically significant difference between the two groups (P =.167), with a hazard ratio for PG of 0.58 (95% confidence interval, 0.27-1.27; P =.173). Subgroup analysis revealed that the hazard ratio for OS was significantly lower in the PG group than in the TG group among patients with tumor diameters <50mm. The long-term survival outcomes of PG and TG for upper-third AGC patients are comparable, suggesting that PG may be an oncologically acceptable option in carefully selected patients.

IntroductionEmergency rooms (ERs) offer valuable learning opportunities for junior residents, yet the time constraints and complexity of interprofessional collaboration often hinder the development of strong educational relationships with attending physicians. This study aimed to explore how junior residents perceive and build educational alliances with attending physicians during a short-term ER rotation, using the framework of the “educational alliance” (EA).MethodsWe conducted semi-structured interviews with fourteen junior residents who completed a two-month ER rotation at an emergency center in Japan. Thematic analysis was applied using an inductive approach, guided by the three core components of the EA: shared goals, agreement on strategies, and development of mutual trust.ResultsNine themes emerged, which aligned with the three core EA components. Residents actively explored and shared their learning goals through both formal discussions and informal interactions with attendings, adjusting them as needed. While struggling with variations in clinical teaching strategies among attendings, residents developed their own styles through reflection and adaptation. Conversely, some residents experienced diminished autonomy due to unilateral instruction or felt conflicted between patient safety and educational challenges. Trust and appreciation toward attendings were formed progressively and were based on their attitudes, communication, and clinical judgment, contributing to psychological safety and deeper engagement.ConclusionDespite time constraints, junior residents can gradually build educational alliances with attending physicians during short-term ER training. The quality of attending physicians’ engagement plays a critical role in supporting residents’ learning and relational development in fast-paced clinical settings.

Abstract Background Percutaneous transluminal septal myocardial ablation (PTSMA) is an effective treatment for hypertrophic obstructive cardiomyopathy (HOCM). It reduces left ventricular outflow tract pressure gradient (LVOT-PG) and improves heart failure symptoms. Appropriate selection of septal branches for ablation is crucial for effective treatment. However, methods for predicting target myocardial mass before the procedure remain unestablished. Coronary CT angiography-based perfusion territory analysis has proven useful for quantifying ischemic myocardium. Yet, its application to PTSMA has not been reported. Purpose To evaluate whether CT perfusion territory analysis can predict ablation volume and guide procedural strategy in PTSMA. Methods We retrospectively evaluated 22 HOCM patients with successful PTSMA. All patients had pre-procedural coronary CT with analyzable septal branch perfusion territories. Procedural success was defined as &amp;gt;50% reduction in LVOT-PG from baseline. In 19 patients, cardiac MRI was performed within 2 weeks post-procedure to measure myocardial edema volume. All patients underwent peak CPK measurement and pre/post-procedure echocardiography. Results PTSMA significantly reduced LVOT-PG (67.9[38.9-97.5] to 12.5[7.7-52.5] mmHg; P&amp;lt;0.001) and BNP (152.1[86.0-461.3] to 97.8[47-308.8] pg/mL; P&amp;lt;0.001). CT-derived perfusion volume showed correlation with MRI-measured myocardial edema volume (r=0.635; P=0.0035, Figure 1). Moreover, CT perfusion volume demonstrated strong positive correlation with peak CPK (r=0.711; P&amp;lt;0.001, Figure 2). Cases requiring multiple-branch ablation had significantly smaller perfusion volume per septal branch than single-branch cases (7.7±2.5 vs 13.5±2.7 ml; P=0.003). Conclusion CT coronary perfusion territory analysis effectively predicts ablation volume and aids pre-procedural planning for PTSMA. When predicted myocardial volume is small, target vessel revision or multiple-branch ablation should be considered.Figure1 Figure2

Concurrent chemoradiotherapy (CCRT) with docetaxel, cisplatin (CDDP), and fluorouracil (5-FU) (i.e. TPF regimen) has yielded favourable outcomes in treating advanced external auditory canal squamous cell carcinoma (EACSCC). However, safety and efficacy have not been compared across TPF-CCRT and CDDP-based regimens. This study thus aimed to assess the feasibility, safety, and efficacy of TPF-CCRT versus CDDP-CCRT. This retrospective study evaluated 20 patients with T3/T4 EACSCC who underwent CCRT between 2007 and 2023. During radiotherapy, the TPF group (n = 10) received two cycles of 50 mg/m2 docetaxel and 60 mg/m2 CDDP on day 1, plus 600 mg/m2 5-FU on days 1-4. Meanwhile, the CDDP group (n = 10) received three cycles of CDDP (80 mg/m2) triweekly or two cycles of CDDP (60 mg/m2) on day 1 and 5-FU (600 mg/m2/day) on days 1-4 during RT. Treatment compliance, incidence of adverse events, progression-free survival (PFS), and overall survival (OS) were compared between the groups. All patients completed radiotherapy. The incidence of grade ≥ 3 adverse events was not significantly different between the TPF and CDDP groups, but leukopenia (any grade) and alopecia occurred more frequently in the TPF group. Two-year PFS (80% vs. 20%, p < 0.01) and OS rates (100% vs. 40%, p < 0.01) were significantly higher in the TPF group. Compared with CDDP-CCRT, TPF-CCRT has excellent feasibility and efficacy and acceptable toxicity for advanced EACSCC, making it a promising treatment option for this malignancy.

Background:Tendon reconstruction is a difficult procedure with unpredictable results, and evaluating and selecting the appropriate muscle tendon is crucial. To improve the results of tendon reconstruction, the authors investigated active muscle contraction during wide-awake local anesthesia no tourniquet (WALANT) surgery, in which the patient can perform active movements.Methods:Among 213 WALANT tendon reconstructions, 148 muscle tendons were evaluated for active contraction distance and passive stretch distance of the muscle tendons, time elapsed before reconstruction, and characteristics and changes in muscle active contraction patterns after verbal instructions.Results:Active contraction and passive stretch distances showed significant positive correlations and flexor muscles displayed larger distances than extensor muscles. Time elapsed before reconstruction did not correlate with either distance. In the flexor digitorum superficialis muscle, active contraction distance was greater in the grip-related ulnar digits, but the late-phase pattern was more frequent. In the extensor indicis proprius muscle, contraction distance on instruction to extend the thumb was smaller than that when instructed to extend the index finger.Conclusion:WALANT surgery is the only procedure in which active contraction distance and characteristics of muscle tendons can be observed intraoperatively, and it appears useful for tendon transfer.

Abstract Background Emergency physicians (EPs) experience impostor syndrome and burnout. This study assessed the incidences of burnout and impostor syndrome and their causative factors in Japanese EPs. Methods This cross-sectional study administered questionnaires to 34 Japanese emergency departments (EDs). The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) scores, Clance Impostor Phenomenon Scale (CIPS) scores, and their correlations with ED- and EP-level factors underwent a multivariable analysis. Results Of the 307 EPs (70.4%) participants 64 (20.8%), 69 (22.4%), and 197 (64.1%) had MBI-HSS scores that indicated a severe degree of emotional exhaustion (EE), depersonalization, and personal accomplishment (PA), respectively; 34 (11.0%) EPs had severe scores for all three components. Regarding participant CIPS scores, 92 (29.9%) had a higher value than the cutoff. The multivariable analysis of MBI-HSS scores determined severe EE scores were associated with sleep periods (odds ratio [OR], 0.699; 95% confidence interval [CI], 0.496–0.983; P = 0.040) and overnight work (OR, 2.375; 95% CI, 1.006–5.603; P = 0.048). Higher CIPS scores correlated with younger age (OR, 0.941; 95% CI, 0.894–0.991; P = 0.022), personal interviews (OR, 2.636; 95% CI, 1.308–5.312; P = 0.007), and overnight work (OR, 2.679; 95% CI, 1.048–6.851; P = 0.040). Conclusions A high level of burnout was experienced by 11.0% of the participants. Although Japanese EPs more severe scores for PA than EPs in other countries, their CIPS scores were similar. To maintain the well-being of Japanese EPs, ED supervisors should consider supporting younger specialists, interviewing effectively, providing adequate sleep periods, and improving overnight work settings.

Background/Objectives: Recently, shear wave elastography (SWE) and dispersion (SWD) targeting the pancreas have been attempted as noninvasive procedures to evaluate personalized conditions. This study aimed to analyze the feasibility of utilizing them for evaluating the individual need of introducing insulin therapy, combined with the C-peptide index (CPI), in patients with type 2 diabetes mellitus (T2DM). Methods: This study involved 51 patients with T2DM aged ≥20 years old and 20 control subjects without impaired glucose tolerance (CTRL). T2DM were divided into non-insulin-treated (non-INS) and insulin-treated (INS) groups. Their background data, shear wave speed (SWS), and dispersion slope (DS) of the pancreas were obtained on the same day. Results: Pancreatic SWS was higher in T2DM than in CTRL (p < 0.0001), with an AUC of 0.840, sensitivity of 89.1%, and specificity of 70.6%, using a Youden index cutoff of 1.31 m/s. INS and non-INS were discriminated with the cutoff value of 1.70 m/s (p = 0.031, AUC 0.736, sensitivity 55.6% and specificity 89.2%). Pancreatic DS of INS and non-INS was 13.52 and 12.16 (m/s)/kHz, respectively (p = 0.046). Using 12.38 (m/s)/kHz as the cutoff, AUC was 0.718, with sensitivity of 88.9%, specificity of 56.8% and negative predictive value of 95.5%. CPI had AUC of 0.724, sensitivity of 66.7% and specificity of 83.3% with the cutoff of 0.63. With combination of SWS and CPI, all patients with SWS < 1.70 m/s and CPI > 0.476 belonged to non-INS. Conclusions: Simultaneous non-invasive SWE and CPI evaluation showed the feasibility for estimating personalized insulin initiation needs in T2DM, integrating biophysical and hormonal perspectives. Further investigation with a larger, multi-center study population is warranted to enhance the level of evidence.

Hypercalcaemia in intravascular large B-cell lymphoma (IVLBCL) is extremely rare, occurring more often in other non-Hodgkin's lymphomas (NHL). A 68-year-old man was admitted with a fever of unknown origin, mild disturbance of consciousness and respiratory failure. Laboratory findings showed hypercalcaemia with elevated parathyroid hormone-related protein (PTHrP) and decreased intact parathyroid hormone and 1,25-dihydroxyvitamin D. The patient was diagnosed with IVLBCL via random skin biopsy. Chemotherapy resulted in complete remission and normalised PTHrP levels. More than half of all cases of hypercalcaemia in NHL are not associated with PTHrP or 1,25-dihydroxyvitamin D, and the cause of the hypercalcaemia is unknown. However, PTHrP levels are elevated in most cases of IVLBCL with hypercalcaemia, which may present as humoral hypercalcaemia of malignancy. Intravascular large B-cell lymphoma, a rare, clinically aggressive type of B-cell non-Hodgkin's lymphoma, is prone to central nervous system disturbances, including altered consciousness.Hypercalcaemia, which causes impaired consciousness, is extremely rare in intravascular large B-cell lymphoma, occurring more often in other non-Hodgkin's lymphomas.Parathyroid hormone-related protein is elevated in most cases of intravascular large B-cell lymphoma with hypercalcaemia, which may present as humoral hypercalcaemia of malignancy.

BackgroundAlthough preβ1-high-density lipoprotein (preβ1-HDL) promotes cholesterol efflux, high fasting preβ1-high-density lipoprotein levels after breakfast are reduced in patients with poorly controlled type 2 diabetes.ObjectiveThis study investigated whether preβ1-high-density lipoprotein binds to triglyceride (TG)-rich lipoproteins (TGRLs) in the postprandial state and is released during lipolysis.MethodsWe measured preβ1-high-density lipoprotein concentrations, lecithin-cholesterol acyltransferase (LCAT) activity, and LCAT-dependent preβ1-high-density lipoprotein conversion before and after breakfast in patients with diabetes. We also performed in vitro studies using TGRLs. Preβ1-high-density lipoprotein was quantified by enzyme-linked immunosorbent assay and native two-dimensional gradient gel (N-2D-gel) electrophoresis.ResultsBefore breakfast, the diabetes group had higher preβ1-high-density lipoprotein concentrations than the healthy controls; after breakfast, levels in the two groups were similar. Neither LCAT mass nor the LCAT-dependent preβ1-high-density lipoprotein conversion rate changed after breakfast. Mixing of fasting plasma with chylomicrons or very-low-density lipoprotein (VLDL) reduced the preβ1-high-density lipoprotein level by 15% ± 4% and 45% ± 10%, respectively. N-2D-gel electrophoresis showed that preβ1-high-density lipoprotein was generated by bacteria-derived TG lipase only from postprandial VLDL of patients with type 2 diabetes.ConclusionPreβ1-high-density lipoprotein binds to TGRLs in the postprandial state and is released during lipolysis, implying that postprandial hyperlipidemia impairs reverse cholesterol transport in patients with poorly controlled type 2 diabetes.