Obihiro Kosei General Hospital

Chronic pruritus is common and often difficult to treat. Although several studies have examined how cleansing agents used during bathing relate to pruritus, the effect of washcloth use during bathing, including whether discontinuation is associated with lower itch, remains unclear. We conducted a single-center retrospective observational study of 79 washcloth users with diverse skin diseases to evaluate pruritus before and after washcloth withdrawal without treatment escalation. Pruritus severity was measured using a 0 to 10 Numerical Rating Scale (NRS), and scores were compared within patients. At baseline, the mean NRS score among users was 4.79, with cotton and synthetic-fiber washcloths showing comparable scores. Among those who discontinued washcloth use without treatment escalation, mean NRS scores decreased from 4.89 to 1.90 (p < 0.0001), while those who continued showed no significant change in pruritus scores (from 3.86 to 3.60; p > 0.9999). Our data suggest that discontinuing washcloth use may be associated with lower pruritus scores and could represent a practical, low-cost, and none-invasive measure for pruritus management warranting prospective evaluation.

IntroductionDiagnostic errors significantly contribute to adverse events, patient harm and malpractice claims. While most research focuses on physicians, allied health professionals (AHPs) also play a critical role in diagnostic processes. Existing studies, primarily based on medical-record reviews, often overlook communication gaps and team dynamics affecting diagnostic accuracy. This study aims to (1) describe the overall characteristics and patterns of diagnostic errors reported in the national adverse-event database and (2) compare the clinical features, diagnostic processes and contributing factors between cases involving physicians and those involving AHPs.MethodsWe examined diagnostic-error reports from 1631 hospitals in the Japan Council for Quality Healthcare database (2010–2023). Cases were identified using predefined keywords, and two independent physicians assessed them using the Revised Safer Dx Instrument and Diagnostic Error Evaluation and Research (DEER) taxonomy. Contributing factors were analysed, and statistical methods explored error patterns and stakeholder comparisons.ResultsAmong 147 654 event reports, 445 cases involved diagnostic errors. The most common errors occurred in diagnostic testing, assessment and follow-up, particularly misinterpretation of pathological or radiological reports on new injuries during hospitalisation. Physicians were the primary responsible providers (79.3%), while nurses were involved in 19.3% of cases. DEER taxonomy analysis revealed that nurses were more associated with errors in presentation, history-taking and physical examination (p<0.001). Additionally, patient-related factors, observation, reporting and training played a significantly greater role in errors involving nurses than physicians (p<0.001).DiscussionBy leveraging expert-assessed unstructured data, this study provides a broader perspective on diagnostic safety. Findings highlight the critical role of AHPs in diagnostic errors. Our study underscores the need for targeted, profession-specific interventions embedded within broader interprofessional initiatives to effectively reduce diagnostic errors and enhance patient safety.

Background:EGFR L858R mutation is associated with poorer efficacy of EGFR-tyrosine kinase inhibitors (TKIs) than EGFR Ex19del in patients with non-small cell lung cancer (NSCLC). However, ramucirumab (RAM) + erlotinib (ERL) therapy exhibited comparable efficacy between patients with L858R mutation and Ex19del mutation (median progression-free survival (PFS): 19.6 vs 19.4 months) in the RELAY study, with favorable PFS for both gene mutations at 19.4 months in the Japanese subset. Meanwhile, the FLAURA study revealed shorter PFS with osimertinib (OSI) for L858R mutation than Ex19del mutation, with poorer PFS in the Japanese subset than in the overall population. The treatment discontinuation rates of RAM + ERL and OSI in Japanese patients were 18% and 29%, respectively. Consequently, RAM + ERL may exhibit superior efficacy and safety in Japanese patients with the L858R mutation.Objectives:To evaluate the therapeutic efficacy and safety of RAM + ERL as a first-line treatment for advanced or recurrent NSCLC harboring the L858R mutation in Japanese patients.Design:A multicenter, noninterventional, retrospective cohort study.Methods and analysis:This study will involve patients with advanced or recurrent NSCLC (ECOG PS score 0–2) with L858R mutation who received RAM + ERL between November 1, 2020 and August 31, 2023, with the planned sample size of 200 patients. The primary endpoint is time to treatment failure, and the secondary endpoints are overall survival, PFS, PFS2, time to discontinuation of any EGFR-TKI, time to failure of strategy, objective response rate, disease control rate, and safety. Exploratory endpoints are effects of ERL and RAM on PD-L1 expression and neutrophil-to-lymphocyte ratio.Discussion:To the best of our knowledge, this is the first retrospective study focusing on L858R mutations associated with the RELAY regimen, providing the corresponding real-world data.Trial registration:UMIN Clinical Trials Registry identifier: UMIN000052047.

Introduction Delayed diagnosis and therapy initiation for pyogenic spondylitis can have severe and fatal consequences. Early diagnosis and intervention are crucial in the treatment of pyogenic spondylitis. This multicenter cross-sectional study with prospective case series aimed to identify factors influencing the time from symptom onset to the diagnosis of pyogenic spondylitis. Methods Patients hospitalized with pyogenic spondylitis between 2019 and 2023 were included. Patients were classified into 2 groups: the delayed diagnosis group (>30 days from the onset of initial symptoms to the diagnosis of pyogenic spondylitis) and the early diagnosis group (within 29 days). Risk factors for delayed diagnosis were analyzed. Results A total of 74 patients (42 men and 32 women; mean age: 70.2 years) from 5 institutions were included. Univariate analysis of risk factors for delayed diagnosis revealed that the significant risk factors included advanced age (p=0.03), low white blood cell count (p<0.01), low C-reactive protein level (p<0.05), and semi-rigid spinal level, based on the spinal instability neoplastic score classification (p=0.05). Multivariate analysis for delayed diagnosis showed that the location at the semi-rigid spinal level was a significant risk factor (p=0.02). The vertebral bone destruction rate and abscess cavity index in the delayed diagnosis group were significantly higher than those in the early diagnosis group (p<0.01 and p<0.01, respectively). Conclusions Significant risk factors for delayed diagnosis of pyogenic spondylodiscitis include infection at the semi-rigid thoracic spinal level. Early diagnosis of spondylodiscitis is crucial because delayed diagnosis can lead to progressive bone destruction and the formation of large abscesses. Increased awareness of thoracic spinal infections, which can easily delay diagnosis, could help in the early diagnosis and treatment of pyogenic spondylodiscitis.

Background and Objectives: The elbow joint, essential for daily activities, often requires soft tissue reconstruction following trauma, infection, or tumor excision. Free flap surgery using the brachial artery (BA) as the recipient vessel offers stable vascular support, but preserving distal blood flow is crucial. Due to vessel diameter differences, end-to-side (ETS) anastomosis is usually necessary, as flow-through anastomosis can be challenging. Although reports exist on soft tissue reconstruction using the BA as the recipient vessel, complications and outcomes related to using the sole main artery as the recipient remain unclear. We developed the microscopic parachute end-to-side (MPETS) technique, adapted from ETS, to more easily address vessel size discrepancies. This study evaluates the effectiveness and safety of MPETS in BA-based elbow reconstruction, alongside a review of outcomes in other cases. Materials and Methods: We retrospectively analyzed seven cases of elbow reconstruction from April 2018 to September 2023, focusing on patients with BA recipient vessels and a minimum 12-month follow-up. Variables included patient demographics, etiologies, flap types, and postoperative outcomes measured by Jupiter's Criteria. Following PRISMA 2020 guidelines, a systematic literature review identified similar cases using the BA in free flap reconstruction for comparison. Results: In all our cases, flap survival was 100%, with no distal ischemia observed, and the average range of motion was 119°. Complications were limited, with one reoperation due to venous thrombosis. The MPETS technique minimized blood flow issues and accommodated the BA's diameter. The literature review included 77 cases, confirming the BA's viability and stability as a recipient vessel. Conclusions: Using the BA as a recipient vessel with MPETS demonstrates high effectiveness and safety in elbow soft tissue reconstruction. Our results support the BA's suitability for complex reconstructions, with MPETS enhancing vessel compatibility and reducing complications.

Acute myeloid leukemia (AML) is an aggressive hematological malignancy with genetic alterations. The FMS-like tyrosine kinase 3 (FLT3) gene is frequently mutated in adult de novo AML, with two types of mutations: internal tandem duplication (ITD) and point mutations in the tyrosine kinase domain. This study aimed to investigate the impact of FLT3 inhibitors and hematopoietic cell transplantation (HCT) on survival outcomes in patients with FLT3-ITD AML in a real-world setting. We retrospectively analyzed 139 patients with FLT3-ITD-positive AML between 2012 and 2021. The median age was 63 years. In the propensity score-matched cohort, FLT3 inhibitors improved overall survival (OS) compared with patients treated without FLT3 inhibitors (3-year OS: 33.7% vs. 25.8%, p = 0.021). Patients who underwent HCT had superior outcomes to those without HCT (3-year OS: 45.3% vs. 2.2%, p < 0.0001). The combination of FLT3 inhibitors and HCT resulted in the highest OS and relapse-free survival (RFS) rates (3-year OS: 62.4%; 3-year RFS: 44.4%). Disease status before transplantation did not predict the prognosis, but use of FLT3 inhibitors increased survival in patients without complete remission before HCT. These results demonstrate the clinical impact of FLT3 inhibitors on survival outcomes in patients with FLT3-ITD-positive AML, particularly when combined with HCT. FLT3 inhibitors can improve the prognosis of AML with FLT3 mutations, especially in patients who undergo HCT.

The purpose of this study was to understand the anatomical and functional connections between the paracentral lobule (PCL) and the primary motor cortex (M1) of the human brain. This retrospective study included 16 patients who underwent resection of lesions located near M1. Nine patients had lesions in the dominant hemisphere. Tractography was performed to visualize the connectivity between two regions of interest (ROIs)-the convexity and the interhemispheric fissure-that were shown by functional MRI to be activated during a finger tapping task. The number, mean length, and fractional anisotropy (FA) of the fibers between the ROIs were estimated. During surgery, subdural electrodes were placed on the brain surface, including the ROIs, using a navigation system. Cortico-cortical evoked potentials (CCEPs) were evoked by applying electrical stimuli to the hand region of M1 using electrodes placed on the convexity and were measured with electrodes placed on the interhemispheric fissure. To verify CCEP bidirectionality, electrical stimuli were applied to electrodes on the interhemispheric fissure that showed CCEP responses. Correlations of CCEP amplitudes and latencies with the number, mean length, and mean FA value obtained from tractography were determined. The correlations between these parameters and perioperative motor functions were also analyzed. Fibers of 14 patients were visualized by diffusion tensor imaging (DTI). Unidirectional CCEPs between the PCL and M1 were measurable in all 16 patients, and bidirectional CCEPs between them were measurable in 14 patients. There was no significant difference between the two directions in the maximum CCEP amplitude or latency (amplitude, p = 0.391; latency, p = 0.583). Neither the amplitude nor latency showed any apparent correlation with the number, mean length, or mean FA value of the fibers obtained from tractography. Pre- and postoperative motor function of the hands was not significantly correlated with CCEP amplitude or latency. The number and mean FA value of fibers obtained by DTI, as well as the maximum CCEP amplitude, varied between patients. This study demonstrated an anatomical connection and a bidirectional functional connection between the PCL, including the supplementary motor area, and M1 of the human brain. The observed variability between patients suggests possible motor function plasticity. These findings may serve as a foundation for further studies.