Ohta Nishinouchi Hospital

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.

Leukocytoclastic vasculitis (LCV) is a disease secondary to infections, malignancies, or drug exposure, although its pathogenesis remains unclear. Secondary LCV from different causes in the same patient has been rarely reported. We present a case of LCV secondary to pancreatic cancer that remained in remission for one year post-surgery, after which the patient suffered from a subdiaphragmatic abscess caused by Escherichia coli, followed by recurrence of LCV. This case suggests that patients with acquired hyposplenism may be susceptible to developing LCV as a manifestation of underlying disease. Careful evaluation of the underlying disease is important to avoid inappropriate immunosuppressive treatment.

Background: Dissection around the superior mesenteric artery (SMA) is a key step for local clearance of periampullary cancers in pancreaticoduodenectomy (PD). Since the 2000s, SMA-first approaches have gained popularity in open surgery to allow early vascular control and resectability assessment. With the rise of robotic pancreaticoduodenectomy (RPD), various SMA dissection techniques have been adapted to the robotic setting. Objective: To map current evidence on SMA dissection techniques in RPD and summarize technical variations. Eligibility Criteria and Sources of Evidence: A PubMed search identified 116 records. After title and abstract screening and full-text review, 27 studies focusing on SMA dissection for periampullary tumors in RPD with sufficient technical detail were included. Studies on open/laparoscopic PD, lacking technical description, or reporting duplicate techniques were excluded. Charting Methods: Data were charted based on the SMA approach type, surgical details, and institution. Results: Among the 27 included studies, multiple approaches were identified—anterior, right posterior, left posterior, uncinate, and mesenteric—each adapted to the robotic platform. Techniques varied in exposure, lymphadenectomy, and vessel control. Conclusions: This scoping review reveals diverse SMA dissection strategies in RPD. While technical innovation is progressing, further studies are warranted to standardize approaches and assess their oncologic and surgical outcomes.

The pharmacokinetic and pharmacodynamic characteristics of remimazolam (RMZ), a novel ultrashort-acting anesthetic, administration alone in clinical practice remain poorly understood. Therefore, we aimed to evaluate the relationship between patient characteristics and the pharmacokinetics and pharmacodynamics of RMZ in older Japanese adults who underwent general anesthesia at the early stage of infusion. Plasma samples were collected from 20 patients (median age: 71.7 years; range: 42.2–88.6 years) who were intravenously administered RMZ without other anesthetics such as remifentanil or fentanyl. The pharmacokinetic profiles of RMZ and its metabolite (CNS7054) were described using three- and two-compartment models with a transit compartment, respectively. The bispectral index was selected as a clinical measure of sedation. The pharmacokinetic-pharmacodynamic profile of RMZ was described using a maximum inhibitory model with an effect compartment. The population pharmacokinetic and pharmacodynamic parameters of RMZ were obtained using the nonlinear mixed-effects modeling program. RMZ clearance (CL) was increased nonlinearly with increasing body weight (BW), and the population mean CL for a typical patient (BW, 60.4 kg) was 1.38 L/min. No patient characteristics affected CNS7054 pharmacokinetics. The population mean of the half-maximal inhibitory RMZ concentration decreased nonlinearly with increasing age or BW. However, these characteristics did not meet the criteria for pharmacokinetic and pharmacodynamic covariates. Our results suggest that BW is an intrinsic factor affecting RMZ pharmacokinetics in Japanese patients under general anesthesia in the early stages of infusion; however, no patient characteristics affected RMZ pharmacodynamics.

It is difficult to distinguish idiopathic multicentric Castleman disease (iMCD) from immunoglobulin G4-related disease (IgG4-RD). A 47-year-old man was diagnosed with venous thrombosis in the right lower extremity. Multiple lymphadenopathies and splenomegaly were incidentally detected. His serum IgG4 levels were high, and the biopsied lymph nodes showed high plasma cell infiltration with many IgG4-positive cells between the follicles. He was initially diagnosed with IgG4-RD and was administered prednisolone 30 mg/day; however, inflammation and IgG4 persisted. The patient was rediagnosed with iMCD and treated with tocilizumab, which led to an improvement of his condition. When diagnosing IgG4-RD, it is therefore important to consider iMCD in the differential diagnosis.

Although previous studies have reported poor outcomes in older-onset (≥ 75 years old) antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) compared with younger-onset AAV, the distinct cause of poor prognosis remains unclear. This study aimed to investigate the clinical features, therapies, and outcomes of older patients with granulomatosis with polyangiitis (GPA) and patients with microscopic polyangiitis (MPA) compared to younger-onset patients. This two-center retrospective cohort study enrolled 70 newly-onset Japanese patients with AAV (GPA and MPA) from the Fukushima Medical University Hospital and Ohta-Nishinouchi Hospital in Fukushima, Japan, between 2004 and 2019. Clinical records were retrospectively reviewed, and clinical features and outcomes (1-year and 3-year survival by the Kaplan-Meier method) were compared between older and younger GPA/MPA groups, respectively. Clinical features of the older GPA/MPA group were similar to those of the younger GPA/MPA group; however, the older GPA group showed severe inflammation and the older MPA group had an increased frequency of renal involvement and fever. The 1-year survival in the older MPA group was significantly lower than that in the younger MPA group. Immunosuppressive therapy including cyclophosphamide, rituximab, and other immunosuppressive agents was important to sustain the survival of patients with GPA/MPA. Older patients with GPA/MPA may have specific clinical features; careful observation is needed during the treatment of older patients with MPA. Immunosuppressive therapy may improve the prognosis of patients with AAV.

Acute coronary syndromes (ACS) often cause rapid decline in renal and cardiac function. In patients with ACS, combined renal dysfunction is associated with increased overall mortality and cardiovascular events. Physical activity (PA) management may crucially contribute towards protection of renal function in patients with ACS. This article describes the study protocol of a randomized controlled trial (RCT) assessing whether online support for PA management using wearable devices and information communication technology for patients with ACS facing difficulties in participating in outpatient cardiac rehabilitation after discharge can protect renal function following disease onset. We have designed a two-arm RCT with a 3-month follow-up period. The online support intervention incorporates monitoring of PA, pulse rate, and blood pressure using a wearable device with an accelerometer and a web application system, as well as periodic educational feedback and goal setting. The primary study endpoint is the estimated glomerular filtration rate based on serum cystatin C (eGFRcys). The intervention effect will be assessed using the eGFRcys at 3 months adjusted for baseline values. The secondary endpoints are the urine albumin/creatinine ratio, brain natriuretic peptide levels, average step count, peak oxygen uptake, quality of life, and incidence of adverse events. This RCT will provide evidence regarding the effectiveness of online support for PA management as a renal protection strategy following ACS onset. This novel strategy not only mitigates barriers impeding participation in outpatient cardiac rehabilitation and protects cardiac and renal function in patients with ACS, but also may contribute towards improving survival and recurrence rates, preventing dialysis, and reducing medical and long-term care costs. The trial was registered in the Japan Registry of Clinical Trials on July 5, 2024. The registration number is jRCT1022240014 (Impact of Online Support of Physical Activity Management Using a Wearable Device on Renal Function in Patients with Acute Coronary Syndrome).

This study aimed to compare the clinical outcomes of total laparoscopic hysterectomy (TLH) and robot-assisted laparoscopic hysterectomy (RALH) for treating symptomatic uterine fibroids at a single institution in Japan. Additionally, we identified factors associated with operative time in each surgical approach. This retrospective cohort study included 163 premenopausal women with symptomatic uterine fibroids who underwent TLH (n = 119) or RALH (n = 44) between October 2021 and March 2025. Clinical characteristics, magnetic resonance imaging findings, and surgical outcomes were reviewed. Operative time was defined as the time from skin incision to closure. Multivariate linear regression analyses stratified by surgical method were performed to identify factors influencing operative time. Operative time was significantly longer in the RALH than in the TLH group (median:208 vs. 176 min, p < 0.001). Multivariate analysis revealed that uterine length (LU) was associated with longer operative time in both groups, whereas parity was associated with reduced operative time in the RALH group. Both UL and parity were independent factors influencing operative time and highlighted the clinical implications of longer operative time in early-phase RALH compared with TLH.

The withdrawal or continuation of angiotensin II receptor blockers (ARBs) before surgery continues to be debated. We hypothesized that this is because ARBs with different half-lives have not been studied individually. This retrospective study aimed to clarify whether the degree of hypotension during anesthesia induction differs among ARBs with different half-lives. We included patients who received general anesthesia with regular oral administration of telmisartan (group T) or valsartan (group V), which have half-lives of approximately 24 and 6 hours, respectively. The frequency of hypotension and vasopressor frequency and dose during anesthesia induction were compared between the two groups. At our hospital, ARBs were withdrawn on the day of surgery in all patients. Groups T and V included 190 and 132 patients, respectively. Patient backgrounds in group V were significantly more strongly associated with the use of calcium channel blockers. No significant differences were observed in the use of other concomitant antihypertensive medications, cardiovascular complications, or renal function. The time during which the mean arterial blood pressure was < 60 mmHg during anesthesia induction was significantly greater in group T than in group V (11 min vs. 7 min, P=0.030). The proportion of patients who used vasopressors was significantly higher in group T than that in group V (74.2% vs. 56.0%, P < 0.001). Patients taking telmisartan showed more hypotensive during the induction of general anesthesia than those taking valsartan, even after withdrawal on the day of surgery.