Sendai Medical Center

Introduction. The rising global incidence of cesarean deliveries has led to elevated abnormal placentation, particularly placenta accreta spectrum (PAS) disorders. These conditions represent serious obstetric complications with high risks for both maternal and fetal morbidity and mortality. А im: to analyze a clinical case of placenta increta with deep invasion, highlighting the diagnostic value of advanced ultrasonographic techniques. Case presentation . A 29-year-old pregnant woman with a history of three cesarean sections (2014, 2017, and 2025) and prominent somatic comorbidities (chronic pyelonephritis and urolithiasis) underwent routine antenatal ultrasound screenings at 8, 12, 20, 23, and 28 +6 weeks of gestation. Standard transvaginal and transabdominal sonographic techniques were used. After sonographic suspicion of placenta increta, magnetic resonance imaging (MRI) was performed for verification. Final diagnosis was confirmed intraoperatively and through histopathological analysis. Ultrasound revealed signs consistent with PAS type 2 (placenta increta): marked thinning of the myometrium, dilated lacunae, retroplacental hypervascularization, and placental bulging. At 28 +6 weeks, transvaginal sonography detected further invasion into the cervical canal (PAS 3a). Color Doppler imaging revealed vascular "rail signs," indicating deep invasion. MRI confirmed complete placenta previa with abnormal tissue growth into the uterine scar and myometrial layers. This case demonstrates the effectiveness of modern ultrasonography and Doppler imaging in the early identification and classification of PAS disorders. Although previous publications emphasized limitations in determining invasion depth via ultrasound, this report highlights its diagnostic reliability, especially when complemented by MRI. Early diagnosis is essential for surgical planning and improving perinatal outcomes. Conclusion . Ultrasound primarily combined with color Doppler imaging, provides a reliable and non-invasive means for diagnosing PAS disorders. In this case, the identification of specific Doppler features – particularly the "rail sign" representing vascular bridging between the myometrium and serosa – proved critical for diagnosing placenta increta. These findings highlight a potential for advanced Doppler markers in improving antenatal detection and surgical planning. Integrating such diagnostic techniques into routine care can markedly improve maternal and fetal outcomes in high-risk pregnancies.

Pulmonary hypertension (PH) due to left heart disease (group 2 PH) is associated with a worse prognosis than isolated heart failure. Both pulmonary arterial hypertension (group 1 PH) and group 2 PH are involved in pulmonary artery (PA) remodeling, which is potentially driven by shared molecular mechanisms. The aim of this study was to investigate the underlying processes contributing to PA remodeling in group 2 PH. To mimic the response to a left-sided pressure load, pulmonary arterial smooth muscle cells (PASMCs) were subjected to mechanical stretch. RNA sequencing of PAs from patients with group 2 PH was performed using the Gene Expression Omnibus database. Mice with transverse aortic constriction and spontaneously hypertensive rats were used as group 2 PH models, and they were treated with adeno-associated virus via intratracheal instillation. RNA sequencing of PASMCs after the stretch stress identified 1585 genes specifically upregulated in PASMCs from patients with group 1 PH. Further PA and plasma analyses from patients with group 2 PH, integrated with group 1 PH findings, identified enhancement of TGF-β (transforming growth factor-beta) signaling by the INHBA (inhibin subunit beta A) as a key feature. Metabolomics revealed that stretch-induced mitochondrial dysfunction in PASMCs caused lactic acidosis via enhancement of PDK1 (pyruvate dehydrogenase kinase 1) and c-MYC, leading to increased INHBA expression. Mice with transverse aortic constriction exhibited increased INHBA expression, decreased PDH (pyruvate dehydrogenase) expression, and acidic alterations in PAs. Targeted silencing of INHBA or PDK1 using adeno-associated virus in mice with transverse aortic constriction attenuated PA remodeling, improved right ventricular function, and reduced PH. Integrated RNA sequencing and metabolomics with stretched PASMCs and animal models identified mitochondrial dysfunction and subsequent acidic alterations as stimulators of increased INHBA expression and TGF-β signaling. These mechanisms contributed to PA remodeling in group 2 PH and provided potential therapeutic strategies.

Intraoperative use of urokinase is a recognized method for salvaging compromised free flaps. However, protocols for dosage and administration vary, and no consensus exists regarding the optimal technique. Herein, we report a case of postoperative venous thrombosis in a free fibular flap. Despite the unsuccessful intra-arterial administration of urokinase owing to an extensive venous thrombus, we attempted to dissolve the thrombus through direct intravenous infusion using a 27 G needle at multiple sites in the vein where the thrombus had formed. Ten minutes after direct injection into the venous thrombus, venous blood flowed out and successful thrombolysis was achieved. Re-anastomosis was performed, leading to full use of the skin flap without partial necrosis. No hemorrhagic complications were observed. Intra-arterial injection of urokinase is an effective method of thrombolytic therapy for flap salvage. However, when the vein is completely occluded by thrombus, intraflap circulation of the agent via arterial infusion becomes difficult. Direct injection of urokinase into the occluded vein may serve as a potential method for resolving venous obstruction within the limited ischemic time of the flap.

Elevated systolic blood pressure (SBP) increases myocardial oxygen demand, whereas low diastolic blood pressure (DBP) can impair coronary perfusion. The prognostic impact of this high-SBP/low-DBP (HSLD) profile in patients with ST-elevation myocardial infarction (STEMI) remains unknown. We analyzed 696 consecutive patients with STEMI undergoing primary percutaneous coronary intervention (PCI) from a prospective 11-center registry in Japan. Patients were categorized based on pre-procedural SBP (≥ 120 mmHg) and DBP (< 70 mmHg) into four groups: high-SBP/low-DBP (HSLD) high-SBP/high-DBP (HSHD), low-SBP/high-DBP (LSHD), and low-SBP/low-DBP (LSLD). The primary endpoint was a 1-year composite of cardiovascular death, non-fatal myocardial infarction, or stroke. Median follow-up was 369 days. The 1-year cumulative incidence of the primary endpoint was 7 (9.5%) in the HSLD group, 19 (4.2%) in the HSHD group, 2 (2.8%) in the LSHD group, and 5 (6.0%) in the LSLD group (log-rank p = 0.007). In multivariable Cox regression, the HSLD was independently associated with the primary endpoint compared to the HSHD group (hazard ratio 3.20, 95% CI 1.04-9.87; p = 0.043). The prognostic value of HSLD was consistent across major subgroups. A pre-procedural blood pressure pattern of SBP ≥ 120 mmHg combined with DBP < 70 mmHg independently predicts a higher risk of adverse cardiovascular events at 1 year in patients with STEMI. This simple measurement at admission identifies a previously unrecognized high-risk phenotype and presents a valuable opportunity for early risk stratification.

Dear Editor, Pilomatricoma is a benign tumor characterized by differentiation from hair matrix cells to hair cortical cells. It commonly occurs on the head and neck in young individuals. Although blistering is rare, when present, it is typically observed on the upper arms, shoulders, and back. The condition is more frequently seen in teenagers and young adults; however, it is rare in young children. [...].

Autistic symptoms have been shown to influence functional outcomes and prognosis not only in schizophrenia but also in individuals at clinical high-risk of psychosis (CHR-P) and those experiencing their first-episode psychosis (FEP). However, it remains unclear whether these symptoms reflect enduring traits that persist over time or whether they are states that can improve with treatment in CHR-P and FEP. This study aimed to investigate the one-year trajectory of autistic symptoms in individuals at CHR-P and with FEP. A total of 59 participants who completed a one-year follow-up [CHR-P, n=34; FEP, n=25] were categorized into high and low autistic symptom groups based on baseline symptom severity, as assessed by the Positive and Negative Syndrome Scale Autism Severity Score. We then examined changes in psychiatric symptoms, including autistic symptoms, as well as global and cognitive function, between the two groups over one year. After one year of follow-up, psychiatric symptoms other than autistic symptoms, as well as global and cognitive function, improved in both groups. The significant differences in these symptoms and functions at baseline disappeared after one year. However, while autism symptoms demonstrated some improvement from baseline, the significant differences between the high and low autistic symptom groups persisted. These findings suggest that autistic symptoms may exhibit both transient state and enduring traits in individuals at CHR-P and with FEP. Further studies with larger sample sizes and follow-up periods exceeding one year are needed to validate the long-term stability of these symptoms.

BackgroundAcute low back pain is a leading cause of disability worldwide. While clinical guidelines offer general management strategies, real-world evidence on nerve block therapy for acute low back pain in primary care remains limited.MethodsWe conducted a prospective, multicenter observational cohort study at 19 private pain clinics in Japan from June 2021 to March 2022. Patients with acute low back pain onset within the past seven days were enrolled and followed for seven days. Clinical decisions, including nerve block administration, were made at the physician’s discretion. Patient-reported outcomes were collected via web- or paper-based questionnaires and compared between patients who received nerve block injections and those who did not. The primary outcome was the change in Pain Disability Assessment Scale (PDAS) scores from baseline to Day 3; secondary outcomes included PDAS changes on Day 7 and Visual Analog Scale (VAS) scores for seven consecutive days. Multivariable regression models were used to adjust for confounding factors.ResultsA total of 567 patients were analyzed (523 injected; 44 non-injected). Among patients with baseline PDAS scores ≥ 45, those who received injections showed significantly greater improvement on Day 3. The mean differences (95％ confidence interval (CI) ) in PDAS scores were -6.42 (-12.48 to -0.36) (P = 0.038) at a baseline score of 45, -11.95 (-21.35 to -2.55) (P = 0.013) at 50, and -17.54 (-31.01 to -4.07) (P = 0.011) at 55. VAS scores were significantly lower in patients with the injection on Day 1 (mean difference (95% CI): -0.70 (-1.37 to -0.04)) and Day 3 (-0.76 (-1.44 to -0.08)), with no significant differences beyond Day 3.ConclusionNerve block therapy was associated with faster pain relief and earlier functional improvement in acute low back pain patients, particularly among those with greater baseline disability. These findings provide meaningful real-world evidence. Given the observational design and the fact that treatment decisions were made at the discretion of attending physicians, there remains a potential for selection bias. Further well-designed studies are needed to validate these findings and guide optimal treatment strategies for acute low back pain.

ABSTRACTExosomal microRNAs (miRNAs) are candidates for liquid biopsies. Organoid culture systems enable long‐term expansion of the colon epithelium. This study evaluated exosomal miRNAs from colorectal cancer organoids for liquid biopsy. Organoids were established from normal colon and colorectal cancer tissues. Exosomes were isolated from conditioned media. miRNAs were extracted from exosomes and compared using microarray analysis. Exosomal miRNAs expression levels in the sera of healthy patients and patients with colorectal cancer were compared at a single institution. The multicenter study was validated using miRNAs upregulated in the serum of colorectal cancer patients, along with exosomal miRNAs reported to be upregulated in colorectal adenoma organoids and sera. A total of 44 exosomal miRNAs were commonly expressed in both normal colorectal epithelial cells and colorectal cancer organoids, whereas 59 were exclusively expressed in colorectal cancer organoids. In a single‐center cohort study, two exosomal miRNAs (miR‐4284 and miR‐5100) were upregulated in the serum of colorectal cancer patients. In a multicenter study, four exosomal miRNAs (miR‐4284, miR‐5100, miR‐1246, and miR‐1290) were upregulated in the serum of patients with colorectal cancer. The combination of these four exosomal miRNAs had comparable diagnostic performance to carcinoembryonic antigen, with an area under the curve of 0.75 (95% confidence interval: 0.65–0.83) versus 0.79 (95% confidence interval: 0.70–0.87). Combining the four miRNAs with carcinoembryonic antigen improved diagnostic accuracy, with an area under the curve of 0.82 (95% confidence interval: 0.74–0.89). Exosomal miRNAs derived from colorectal cancer organoids can serve as diagnostic biomarkers for colorectal cancer.