Toyama Prefectural Central Hospital

BackgroundThe measurement of computed tomography dose index 100 (CTDI100), which is feasible only through axial scanning, requires that the clinical spiral protocols be replaced with those for axial scanning. The real‐time ionization chamber detects the integral of radiation dose rate profile, enabling the direct verification of the volume CTDI on spiral CT scanning (CTDIvolSpiral).PurposeThis study aimed to develop a direct measurement technique for CTDIvolSpiral and compare its accuracy with that measured using axial scanning (CTDIvolAxial) or that displayed on the console (CTDIvolDisplayed).MethodsA CTDI phantom with a real‐time ionization chamber was placed on the headrest or examination table. CTDI100Axial was measured with following parameters: tube voltage = 120 kV, effective mAs = 100, and rotation time = 1.00 s. The parameters for measuring CTDI100Spiral were set identical to those used for axial scanning, except for rotation times = 0.33, 0.50, and 1.00, pitch = 0.35, 0.50, 0.75, 1.00, 1.25, and 1.50, and the scanning range = 15 cm. CTDI100Spiral was extracted from the integral of radiation dose rate profile. CTDIvolSpiral was subsequently calculated and compared with CTDIvolAxial and CTDIvolDisplayed. Finally, CTDIvolSpiral was measured for 10 clinical protocols and compared with CTDIvolDisplayed.ResultsThe differences between CTDIvolAxial and CTDIvolDisplayed, CTDIvolSpiral and CTDIvolDisplayed, and CTDIvolAxial and CTDIvolSpiral for the head and body phantoms were all < −2.0%. The differences between CTDIvolDisplayed and CTDIvolSpiral for scans on clinical protocols with and without automatic exposure control were < 11.9% and < 10.5%, respectively; these large differences were observed in the dual‐energy twin‐beam protocol. Excluding this protocol yielded differences between the measurements with and without automatic exposure control of < 2.0% and < −3.9%, respectively.ConclusionsThe results showed an excellent agreement between CTDIvolAxial and CTDIvolSpiral, supporting the use of the clinical spiral CT scanning to verify CTDIvolDisplayed using a real‐time ionization chamber.

Cytokine storm syndrome (CSS), commonly associated with hemophagocytic lymphohistiocytosis (HLH), is a fatal hyperinflammatory syndrome. Differentiating the underlying diseases responsible for CSS is essential for timely therapeutic decisions. This study explored the clinical usefulness of serum cytokine profiling in distinguishing underlying diseases in patients with CSS. Serum samples were collected from 143 adult and pediatric patients with CSS and 22 healthy controls. The cohort included patients with various diagnoses of primary and secondary HLH and Kawasaki disease (KD)-like hyperinflammatory syndromes. Serum levels of 48 cytokines were analyzed in 97 patients using a bead-based multiplex immunoassay (Luminex assay). Serum levels of interferon alpha (IFN-α), interleukin-18 (IL-18), IL-6, CXCL9, and soluble tumor necrosis factor receptor II (sTNF-RII) were measured in 165 participants using enzyme-linked immunosorbent assay (ELISA). Luminex assay categorized patients with CSS into five clusters based on serum cytokine patterns. ELISA revealed distinct cytokine patterns, wherein patients with histiocytic necrotizing lymphadenitis-associated HLH and systemic lupus erythematosus-associated macrophage activation syndrome (MAS) showed elevated IFN-α; systemic juvenile idiopathic arthritis-associated and adult-onset Still's disease-associated MAS, X-linked inhibitor of apoptosis protein deficiency with HLH, and NLRC4-associated autoinflammatory disorder exhibited higher IL-18 levels. Additionally, KD shock syndrome had higher IL-6 levels than the other groups. CXCL9 was significantly elevated in patients with virus-associated HLH, familial HLH, malignant lymphoma-associated HLH, and KD-MAS. Multisystem inflammatory syndrome in children and toxic shock syndrome also showed moderate elevations of CXCL9 and IL-6 levels. Serum cytokine profiling effectively differentiates CSS subtypes, facilitating better diagnosis and personalized treatment strategies based on specific disease backgrounds.

The Japanese Dermatological Association aimed to prepare a second edition of guidelines for the management of diabetic ulcer/gangrene with emphasis on the diagnosis and treatment of skin symptoms. This new edition serves as a tool to improve the quality of the diagnosis and treatment in each patient and, further, to improve the level of care for such skin conditions. All sections have been updated by collecting documents published since the publication of the first edition. In the antibacterial drug treatment for bacterial infection of ulcers, oral administration was added after consideration. In the treatment of antibacterial drugs for bacterial infection of ulcers, not only infusion but also oral administration was mentioned. In addition, clinical questions (CQs) for imaging tests for diagnosing ischemia of the limbs were newly created. The titles of some CQs were changed to conform to the actual clinical setting. (i) The content has been updated by adding and collecting documents for all sections; (ii) we have additionally included oral antibiotic treatment for bacterial infection of ulcers; (iii) we have added CQs pertaining to imaging tests for diagnosing ischemia of the limbs; and (iv) we have revised the titles of some CQs to conform to the actual clinical setting. In particular, the recommendation levels of dressing materials newly covered by Japanese national health insurance are mentioned. In addition, CQs regarding the initial treatment of electrical (CQ15) and chemical burns (CQ16), and the use of escharotomy (CQ22) have been created.

Clinical trials rarely focus on elder patients with castration-resistant prostate cancer (CRPC), and data on the outcomes of second-generation androgen receptor signaling inhibitors (ARSIs) remain limited. The ENABLE study for prostate cancer was an investigator-initiated, multicenter, randomized controlled trial conducted in Japan to compare enzalutamide (ENZ) and abiraterone plus prednisolone (ABI). This sub-analysis was performed to evaluate the efficacy and the safety profiles between patients aged ≥ 75 (older) and < 75 years (younger), and then between the ENZ and ABI arms in the older and the younger cohort separately. The ENZ arm included 41 younger and 51 older patients, while the ABI arm included 36 younger and 56 older patients. No significant differences in survival endpoints were observed between younger and older patients. Median time to prostate-specific antigen (PSA) progression (TTPP) was 15.2 months for younger and 21.2 months for older patients (HR 0.84, 95% CI 0.53-1.33, p = 0.4647). Median overall survival (OS) was 33.7 months for younger and 37.8 months for older patients (HR 0.80, 95% CI 0.50-1.29, p = 0.3651). Among older patients (n = 107), the ENZ arm had a TTPP of 21.2 months compared to 10.1 months for the ABI arm and an OS of 37.8 months compared to 44.7 months for the ABI arm (p = 0.1506 and p = 0.9321, respectively). Any grade and grade ≥ 3 adverse events were observed in 47 (61%) and 11 (14%) younger patients and 73 (68%) and 18 (17%) older patients, respectively. No significant differences were found in any grade or grade ≥ 3 adverse events between younger and older patients (p = 0.3487 and p = 0.6885, respectively). ARSIs demonstrated similar efficacy and safety in both younger and older patients. ENZ may be a more suitable option for older patients due to its higher PSA response rate. This trial was registered with the University Hospital Medical Information Network (UMIN) Center under identifier UMIN000015529.

Adjuvant anti-PD-1 (adj PD-1) antibodies are extensively used to improve survival in patients with resected melanoma. Clinical trials on adj PD-1 antibodies have revealed significant improvements in recurrence-free survival (RFS); however, few of these trials have included patients with acral melanoma (AM). Clinical data were retrospectively collected from Japanese patients who underwent resection of stage III sole AM between 2014 and 2021. Survival outcomes, including RFS, distant metastasis-free survival (DMFS), and overall survival (OS), were compared between patients without adjuvant therapy (OBS group) and those receiving adj PD-1 group. This study included 139 patients (OBS: 79; adj PD-1: 60), with a median follow-up of 2.6 years. The baseline characteristics were comparable, except for age and nodal metastasis. No significant differences in survival were observed between the OBS and adj PD-1 groups (3-year RFS: 36.7% v 27.5%, P = .13; 3-year DMFS: 51.0% v 45.3%, P = .51; 3-year OS: 65.3% v 67.4%, P = .45). Multivariate analysis showed no survival benefit of adj PD-1 (RFS: hazard ratio [HR], 1.25, P = .29; DMFS: HR, 1.03, P = .89; and OS: HR, 0.69, P = .23). Each survival outcome after propensity score matching confirmed no significant difference between the matched OBS group (n = 52) and adj PD-1 group (n = 52; 3-year RFS: 34.3% v 25.9%, P = .22; 3-year DMFS: 45.6% v 46.5%, P = .85; 3-year OS: 60.7% v 68.9%, P = .29). Adj PD-1 did not improve the prognosis in sole AM. However, further studies are essential to evaluate the efficacy of the adj anti-PD-1 antibody in AM.

Abstract Background Fingolimod is associated with an increased risk of developing progressive multifocal leukoencephalopathy (PML). Case Presentation We report a 63‐year‐old woman with severe clinical decline (Expanded Disability Status Scale increasing from 3.5 to 7.0). She started fingolimod 0.5 mg/day at the age of 51 years in the FTY720 trial in Japan, and has been taking it orally ever since. Brain magnetic resonance imaging showed abnormal signals from the subcortical region to the deep white matter, mainly in the right frontal lobe. No gadolinium‐enhancing lesions were observed, and diffusion‐weighted imaging showed marginal hyperintense and central hypointense signals; the characteristic findings in PML. We found her cerebrospinal fluid was positive for John Cunningham polyomavirus DNA, and the diagnosis of PML was made. We administered several steroid pulses in case of immune reconstitution inflammatory syndrome. The progression of symptoms and the enlargement of magnetic resonance imaging lesions stopped after 3 months. Conclusions This case shows that PML should always be kept in mind as a side‐effect of disease‐modifying therapy for multiple sclerosis.

Cervical spine injuries in the elderly (defined as individuals aged 65years and older) are increasing, often resulting from falls and minor trauma. Prognosis varies widely, influenced by multiple factors. This study aimed to develop a deep-learning-based predictive model for post-injury outcomes. This study analyzed a nationwide dataset from the Japan Association of Spine Surgeons with Ambition, comprising 1512 elderly patients (aged 65years and older) with cervical spine injuries from 2010 to 2020. Deep learning predictive models were constructed for residence, mobility, and the American Spinal Injury Association Impairment Scale (AIS). The model's performance was compared with that of a traditional statistical analysis. The deep-learning model predicted the residence and AIS outcomes with varying accuracies. The highest accuracy was observed in predicting residence one year post-injury. The model also identified that the AIS score at discharge was significantly predicted by upper extremity trauma, mobility, and elbow extension strength. The deep learning model highlighted factors, such as upper extremity trauma, that were not considered significant in the traditional statistical analysis. Our deep learning-based model offers a novel method for predicting outcomes following cervical spine injuries in the elderly population. The model is highly accurate and provides additional insights into potential prognostic factors. Such models can improve patient care and individualize future interventions.

Objective: This study identifies the non-technical skills required for robotic surgery and presents improvement efforts.

The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Appendix S1. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.