Saiseikai Wakakusa Hospital

Cervical insufficiency is a major cause of second-trimester pregnancy loss and preterm birth. When transvaginal cerclage is ineffective or not feasible due to prior cervical surgery or a short cervix, transabdominal cerclage is a recognized alternative. However, performing transabdominal cerclage during pregnancy is more technically demanding than pre-pregnancy due to uterine enlargement and increased vascularity. An optimal approach minimizes contact with the pregnant uterus and avoids obstructing uterine artery flow. To meet these goals, we developed a laparoscopic technique called LAC-D (Laparoscopic trans-broad-ligament Abdominal Cerclage with round ligament suspension to create a space in the pouch of Douglas during pregnancy) during pregnancy. This method elevates the uterus naturally by suspending both round ligaments to the anterior abdominal wall for temporary transfixation, creating space in the pouch of Douglas without direct manipulation. This allows safe placement of the suture while maintaining uterine artery blood flow by ligating the cervix medial to the ascending uterine artery. The procedure was performed in 12 pregnant women, with no pregnancy losses. LAC-D might show promise as a minimally invasive and effective surgical option for cervical support during pregnancy, offering technical advantages and favorable outcomes.

This study aimed to compare the biomechanical stress at the proximal junctional aspect between the conventional pedicle screw (PS) fixation (PSF) and the low PS density fixation (LPF) method. This study involved 10 patients, half of whom have non-osteoporosis and the other half have osteoporosis. We made two types of intact models (one is from the upper thoracic-to-pelvis model, and the other is from the lower thoracic-to-pelvis model). From the intact models, we constructed two kinds of fusion models: (1) PSF and (2) LPF. The LPF method was as follows: The claw hooks (the combination of the down-going transverse process hooks and facet hooks) were set at the upper instrumented vertebra (UIV) and sublaminar wires at the thoracic spine and PSs at the lumbo-pelvis. Upper thoracic to pelvis fixation model In non-osteoporosis, no significant difference between the PSF and LPF is found. In osteoporosis, the von Mises stresses of the vertebra body at UIV, UIV+1, and disc were significantly lower in LPF than in PSF. Lower thoracic-to-pelvis fixation model In non-osteoporosis, the average von Mises stress of the vertebral body at UIV+1 and the maximum stress at UIV were lower in LPF than in PSF; however, no significant difference was found in the others. In osteoporosis, the von Mises stress was significantly lower in LPF than in PSF. The claw hooks stabilized the vertebra body at UIV firmly, and sublaminar wires reduced load translation from the fixed spine.

Background: Aged heart failure (HF) patients without dementia have a risk of cognitive impairment (CI) that attenuates the effect of treatment for HF. White Matter Hyperintensity (WMH) and gray matter atrophy in parahippocampal gyrus (PHG) are a potential risk of CI. However, it is not clear whether location and volume of local WMH is associated with atrophy in PHG and predicts prognosis of HF patients. Hypothesis: In HF patients without dementia, local WMH volume is associated with brain atrophy of PHG and predicts prognosis. Methods: We enrolled sixty-one HF patients (age 76±11 years, NYHA class II, EF47±17 %) in the study. We excluded patients with dementia using mini-mental state examination. We took 3D-T1 weighted images and Fluid Attenuated Inversion Recovery (FLAIR) images of whole brain using 1.5T magnetic resonance imaging (MRI). We performed image analysis using 2mm voxel-based morphometry with Statistical Parametric Mapping to evaluate the local WMH volume in the frontal, temporal, parietal, and occipital lobes, as well as the corpus callosum (CC), and to assess the severity of PHG atrophy. We quantified the severity of PHG atrophy using Z-scores. We constructed receiver operating characteristic (ROC) curves to determine the cut-off point of the each local WMH volume for estimating cardiac death and admission due to HF. We constructed Kaplan-Meier Curves adjusted with age, sex, presence of atrial fibrillation, diabetes, dyslipidemia, and blood pressure using inverse probability weighting method. Results: Local WMH volume of CC demonstrated the highest prognostic accuracy (area under the ROC curve 0.73). We divided patients into High-WMH group (n=36, volume of WMH in CC 0.65±37 mL) and Low-WMH group (n=25, volume of WMH in CC 0.14±0.07 mL) according to the cut-off value (0.24 mL) of local WMH volume in CC. As shown in representative cases in Figure1, the Z-score value in PHG (pink circle) was higher in High-WMH group (1.43±0.77) compared to Low-WMH group (0.93±0.63, P=0.01). Adjusted Kaplan-Meier curves showed poor prognosis of High-WMH group (Figure 2). Conclusions: In HF patients without dementia, local WMH in corpus callosum is a potential risk of CI and predicts poor prognosis.

患者：83 歳，男性

Introduction Osteoporotic vertebral compression fracture (OVCF) in the elderly is a major public health concern. This retrospective case-control study aimed to determine the difference in interobserver reliability between radiography, magnetic resonance imaging (MRI), and computed tomography (CT), respectively, and whether CT radiological findings can predict prolonged back pain at 2 weeks after OVCFs. Methods Patients were divided into the prolonged back pain group or the recovered back pain group depending on the numerical rating scale at 2 weeks after admission. Radiography, MRI, and CT images were classified on the basis of conventions described by previous classifications. Interobserver reliability was calculated on images rated by two board-certified spine surgeons. Multivariate logistic regression models were used to evaluate whether the presence or absence of anterior wall injury, endplate deficit, posterior wall injury, lateral wall injury, or intervertebral disc deficit on CT was predictive of prolonged back pain. Results Of the 130 patients, 89 cases (68.5%) involved prolonged back pain at 2 weeks after admission. Neither average age (79.8 vs. 80.1 years, respectively) nor duration to initial consultation (9.4 vs. 6.4 days, respectively) differed significantly between the prolonged and recovered back pain groups. Interobserver reliability was 0.51, 0.77 (0.67-0.86), and 0.82 (0.72-0.92) for radiography, MRI, and CT, respectively. After adjusting for confounding factors such as age, sex, duration to initial consultation, and extent of OVCF, the multivariate analysis showed that the presence of endplate deficit and posterior wall injury was a significant predictive factor for prolonged back pain (odds ratio [OR] 8.5, area under the curve (AUC); 0.79 and OR 2.5, AUC 0.72), respectively.Conclusions Good reliability assessments of CT-based evaluations were noted. After a detailed novel CT evaluation at initial presentation, the presence of an endplate deficit and posterior wall injury was the significant risk factor for prolonged back pain at 2 weeks after an OVCF.

In the present study, in order to elucidate the pathophysiology of vestibular migraine (VM), we performed electronystagmography (ENG) during the interictal period in seven patients with VM diagnosed according to the International Classification of Headache Disorders (ICHD-3β). The results of audiometry, posturography, and CT/MRI revealed no abnormalities in any of the patients. The characteristic ENG findings were as follows: 1) In the dark, lateral and vertical gaze nystagmus were recognized. 2) In the dark, abnormal eye movements, such as square wave jerks, rebound nystagmus and hypometric saccades were frequently observed. 3) In the vertical eye tracking test (ETT), saccadic pursuit was prominent, whereas horizontal smooth pursuit was preserved. 4) The peak velocity of the slow phase in optokinetic nystagmus (OKN) was markedly reduced in three VM patients (43%). 5) The optokinetic after-nystagmus (OKAN) showed the “inhibition pattern” in four patients (57%), and the “disinhibition pattern” in three patients (43%). 6) Caloric nystagmus could be normally induced in two patients. An “ataxic patterm” was observed in two patients. In contrast, the remaining two patients showed suppressed or scarce responses, which suggested peripheral vestibular dysfunction. Except in such cases with peripheral-type abnormalities, most of the aforementioned ocular motor abnormalities were suggestive of dysfunction of both the medial vestibular nuclei (MVN) and the vestibulocerebellum. Although the precise pathophysiology of VM still remains unclear, several hypotheses have been advanced. First, the vascular hypothesis suggests that VM is associated with subclinical microischemic lesions, mainly in the posterior circulation, caused by episodes of vasoconstriction during successive migraine attacks. Second, recent genetic studies have disclosed similarities between familial hemiplegic migraine, which is considered as a Ca2+ channelopathy, and spinocerebellar ataxia type 6 (SCA6). Although no mutations have been identified until now in the common forms of migraine, it is speculated that the Ca2+ channels could be functionally impaired by subtle genetic changes, such as gene polymorphisms, resulting in cortical hyperexcitability; the latter would increase the susceptibility for cortical spreading depression (CSD) over the medulla (vestibular nuclei) and vestibulocerebellum. In conclusion, VM appears to be a heterogeneous central vestibular disorder, and various pathophysiological mechanisms may be mutually involved.

症例 ： 37 歳，女性

A 64-year-old man underwent vascular graft surgery for an abdominal aortic aneurysm one year previously. Using esophagogastroduodenoscopy (EGD), he was definitively diagnosed as having an aortoenteric fistula (AEF) and underwent an urgent surgical procedure for treatment. Generally, the prognosis in cases of AEF after vascular graft operation remains poor, and the survival rate in cases of AEF that require surgery is low.

症例は66歳男性で34歳時にクローン病を発症し，計4回の手術を経て5年間の寛解を維持していた．今回，貧血，低アルブミン血症，上腹部に軟性腫瘤による膨隆を認め精査目的に入院となった．画像検査により消化管間質腫瘍を疑い手術を施行した．大網内に一部が胃に付着した血管に富む腫瘤（19×12×4cm）を認めた．病理組織検査では紡錘形細胞の不規則増殖像と胃側への浸潤像を認め，免疫染色検査ではKIT，CD34およびDOG-1が陽性であったことから大網原発のEGISTと診断した．