Saitama Medical University Hospital

ABSTRACTPatients with poor Eastern Cooperative Oncology Group performance status (ECOG PS) ≥ 3 may be considered for systemic chemotherapy when the decline is driven by reversible tumour‐related factors, but assessing reversibility is often difficult, and some patients ultimately receive best supportive care. We report the case of a 76‐year‐old man with extensive‐stage small cell lung cancer (SCLC) whose condition declined to PS 3 due to obstructive jaundice from pancreatic metastasis and a painful femoral fracture. Biliary stenting improved hepatic function; however, after the first cycle of carboplatin and etoposide, the femur fractured completely, requiring bipolar hemiarthroplasty. Postoperatively, PS improved, enabling the continuation of chemotherapy with carboplatin, etoposide and atezolizumab. Imaging demonstrated regression consistent with partial response, and PS improved to 1. This case emphasises that repeated PS assessment and multidisciplinary management of reversible conditions, including obstructive jaundice and a pathological fracture, can facilitate systemic therapy in poor‐PS SCLC.

BackgroundThe Saitama Tone Health and Medical Care Region Medical Collaboration Promotion Council has established a regional medical network system (Patient-Centered Digital Health Records, Tonetto) that shares medical information among healthcare facilities and provides medical services to Tonetto users. This system has facilitated the sharing of medical information between core hospitals, general hospitals, and clinics, thereby contributing to improved medical care. Furthermore, Tonetto has facilitated the availability of patient information for emergency transport. This study aimed to evaluate the impact of Tonetto on emergency transportation times for older patients.MethodsThe study population consisted of 1,820 older patients (aged 65 and over) among 2,542 emergency patients transported to East Saitama General Hospital between January and December 2023. Based on their registration status in the Tonetto system, the patients were divided into two groups: a Tonetto-registered group (n = 319) and a Tonetto-nonregistered group (n = 1,501). Statistical analysis was performed using a general linear model that included main effects and interaction terms for the three categories of transport distance (< 5, 5–10, and ≥ 10 km) and two categories of Tonetto registration status. The difference in transport time was estimated based on Tonetto registration status for each transport distance category. To control for confounding variables, the model included severity, age, sex, and transport distance as covariates.ResultsThe difference in transport time (minutes) between the Tonetto-nonregistered group and the Tonetto-registered group (95% confidence interval) was − 0.3 (− 3.0, 2.4), − 3.5 (− 8.9, 1.9), − 24.3 (− 38.3, − 10.2), respectively. A reduction of 24 min in transport time was observed in the Tonetto-registered group for distances of 10 km or more (p = 0.001).ConclusionsTonetto registration was associated with a substantial reduction in emergency transport time for older patients over long distances. These findings demonstrate the potential of regional medical information networks to improve the efficiency of emergency care and support the development of a nationwide emergency medical information system in Japan.

Patients have been recently reported who had a common symptom of unilateral photophobia. The electroretinograms (ERGs) recorded from the eyes of these patients had a negative shape with the a-wave normal to slightly attenuated, and the rod and cone responses severely reduced, i.e., a-wave > b-wave. The patients did not complain of night blindness, and the visual acuity and color vision were relatively well preserved. These patients were diagnosed with acute diffuse occult inner retinopathy (ADOIR). We report our findings in such a case in which the unilateral findings progressed to the fellow eye. In the end, we diagnosed our case with bilateral ADOIR. The patient was a 75-year-old woman whose main complaint was photophobia. She had undergone cataract surgery on both eyes by a neighborhood ophthalmologist. However, her symptoms did not improve, and she was referred to the Saitama Medical University Hospital in May 202X. At our initial examination, she did not complain of night blindness, and her decimal visual acuity in the right eye was 1.0 and that of her left eye was 0.9. The fundus photographs and optical coherence tomographic (OCT) images and Goldmann perimetric visual fields were within normal limits. The full-field mixed electroretinograms (ERGs) had a negative shape with severely reduced rod, cone, and flicker responses in the right eye. Multifocal ERGs showed reduced responses only in the macula of both eyes. We conclude that our patient had bilateral ADOIR. The ERGs were the key for reaching this diagnosis and would be important for determining the mechanism of photophobia that occurs at the retinal level.

Human 17β-hydroxysteroid dehydrogenase type 10 (HSD10) is a rare X-linked mitochondrial disorder caused by mutations in the HSD17B10 gene. It is typically associated with neurodegeneration and cardiomyopathy in severe cases. The neonatal form often has a poor prognosis; however, its clinical spectrum remains unclear. Herein, we present a neonatal-onset case of HSD10 disease with a previously unreported HSD17B10 variant presenting with early-onset cardiomyopathy triggered by a viral infection. A male infant presented with lactic acidosis and hypoglycemia on the first day of life. Initial treatment improved metabolic status. He was diagnosed with HSD10 disease using a targeted panel of nuclear and mitochondrial genes, which identified a novel hemizygous variant, NM_004493.3: c.34G>A p.(Val12Met). Cardiac function was normal at five months, but neurodevelopmental regression occurred at six months following vaccination. At seven months, viral myocarditis was diagnosed following rhinovirus/enterovirus infection. Echocardiography revealed a reduced left ventricular ejection fraction and ventricular dilation. Despite supportive therapy, cardiac function deteriorated, leading to death at nine months. A patient with a novel HSD17B10 variant showed early-onset cardiomyopathy in a neonatal case of HSD10 disease and rapid and fatal deterioration of cardiac function. This report highlights the importance of clarifying genotype-phenotype correlations to guide the diagnosis and management of rare mitochondrial diseases.

AimThis study aims to evaluate the associations between the copper/zinc (Cu/Zn) ratio and inflammatory biomarkers and the incidence of chronic kidney disease (CKD) in individuals with type 2 diabetes and to validate our previous cross-sectional study using the baseline data of this study.MethodsWe conducted a prospective, observational study of 416 individuals with type 2 diabetes without CKD. We used multivariable Cox proportional hazard models to determine the HRs for CKD incidence. The Cu/Zn ratio and soluble tumor necrosis factor-α receptor 1 (sTNFαR1) concentrations (pg/mL) were analyzed as continuous variables and as categories classified according to each cutoff value for detecting CKD. The high-sensitivity C-reactive protein (hsCRP) concentrations between these categories were compared.ResultsCKD was identified in 165 participants. The Cu/Zn ratio and sTNFαR1 concentrations were identified as significant predictors, independent of each other, after full adjustment (P = 0.048 and P = 0.006, respectively). Compared to the Cu/Zn <1.281 and sTNFαR1 <1081 group, the HRs for the CKD incidence were significantly higher in the Cu/Zn <1.281 and sTNFαR1 ≥1081 group (HR 2.06, 95% CI 1.34-3.26) and even higher in the Cu/Zn ≥1.281 and sTNFαR1 ≥1081 group (3.29, 1.97-5.50) after full adjustment. The hsCRP concentrations were significantly highest in the Cu/Zn ≥1.281 and sTNFαR1 ≥1081 group compared with the other three groups (all P < 0.05) and were significantly higher in the Cu/Zn ≥1.281 and sTNFαR1 <1081 group and in the Cu/Zn <1.281 and sTNFαR1 ≥1081 group compared with those in the Cu/Zn <1.281 and sTNFαR1 <1081 group (both P < 0.05).ConclusionsThe Cu/Zn ratio and sTNFαR1 concentrations are independent predictors of the incidence of CKD in individuals with type 2 diabetes. Furthermore, under elevated sTNFαR1 concentrations, an increase in the Cu/Zn ratio may further aggravate inflammation and accelerate the incidence of CKD in individuals with type 2 diabetes. These new findings are supported by the results from our previous cross-sectional study.

PurposeTo compare intraocular lens (IOL) stability and reversibility in phacovitrectomy with air or gas tamponade between one- and three-piece intraocular lenses (IOLs).Study designThis retrospective cross-sectional study was conducted at Saitama Medical University Hospital from January to July 2023.MethodsThis study involved 19 patients who underwent phacovitrectomy with either air or sulfur hexafluoride gas tamponade and postoperative anterior segment optical coherence tomography. Patients who underwent NSP-3 (NIDEK Co., Ltd., Japan) or NX70s (Santen Pharmaceutical Co., Japan) implantation were evaluated. The displacement force (mN) of the IOL was evaluated in a verification experiment using the NSP-2 (NIDEK Co., Ltd., Japan) and the NX70s. The NSP-2 and NSP-3 share the same lens platform. ResultsThe median age was 66 (58, 77) [median (quartiles)] years for NX70s (n=8) and 67 (55, 71) years for NSP-3 (n=11). The anterior chamber depth (ACD) and IOL position values were substantially elevated after the air or gas disappeared for both IOLs. Comparing the IOLs for the ACD and IOL positions at each time point, no significant difference was found in the ACD and IOL position values in 100% gas or air.However, ACD and IOL position values of the NSP-3 were markedly higher than those of the NX70s in 0% gas or air. In the verification experiment, NSP-2 required a higher IOL displacement force than the NX70s. Following 48 h of 0.5 mm push, the percentage change in the axial distance was smaller for NSP-2 (−6.9%) than for NX70s (−15.5%).ConclusionNSP3 was as stable as NX70s in phacovitrectomy with tamponade and demonstrated better reversibility than NX70s.

A 55-year-old man with a 13-year history of alcohol-related cirrhosis was admitted for the management of refractory ascites. On day 4 of hospitalization, he developed dyspnea, and chest computed tomography (CT) revealed ground-glass opacities and reticular shadows in both lungs, predominantly in the left upper lobe. Aspiration pneumonia was initially suspected, and cefmetazole was administered. However, by day 11, his respiratory status deteriorated, with SpO₂ dropping to 90%. A follow-up chest CT showed progression of bilateral ground-glass opacities. Further testing revealed an elevated β-D-glucan level of 142.5pg/mL and KL-6 level of 1.770U/mL, along with a positive sputum PCR for Pneumocystis jirovecii, confirming a diagnosis of pneumocystis pneumonia (PCP). As human immunodeficiency virus (HIV) testing was negative, he was diagnosed with non-HIV PCP. Despite treatment with trimethoprim-sulfamethoxazole and hydrocortisone, he died on day 17. Notably, his peripheral lymphocyte count was below 500/μL before admission, suggesting that cirrhosis-associated immune dysfunction (CAID) contributed to his susceptibility to non-HIV PCP. This case highlights the importance of monitoring peripheral lymphocyte counts in patients with advanced liver cirrhosis, as CAID may increase the risk of life-threatening infections such as non-HIV PCP.