[A case of R0 resection in conversion surgery after duodenal stent placement for locally advanced unresectable pancreatic cancer with duodenal stenosis].

A 67-year-old man presented to our hospital with vomiting. Esophagogastroduodenoscopy revealed duodenal stenosis and atypical epithelium. A tumor in the pancreatic head, about 30mm in size, involving the superior mesenteric artery and a superior mesenteric vein was identified using abdominal contrast computed tomography (CT). Locally advanced pancreatic cancer was diagnosed in the patient through an endoscopic biopsy. Due to the duodenal stenosis complication, duodenal stent placement was conducted. After stent placement, oral intake was resumed, and improvement of the systemic condition led to chemotherapy (modified FOLFIRINOX). After chemotherapy, CT revealed decreased carcinoma progression and vascular invasion. Conversion surgery was improved, and R0 resection was achieved. Our study showed that duodenal stent placement could enhance prognosis;as a result, it was regarded as a good choice for multidisciplinary therapy.

Nationwide multicenter study on adverse events associated with a patency capsule: Additional survey of appropriate use of patency capsule study.

BACKGROUND AND AIM: The PillCam patency capsule (PC) without a radio frequency identification tag was released to preclude retention of the small bowel capsule endoscope (CE) in Japan in 2012. We conducted a multicenter study to determine tag-less PC-related adverse events (AEs). METHODS: We first conducted a retrospective survey using a standardized data collection sheet for the clinical characteristics of PC-related AEs among 1096 patients collected in a prospective survey conducted between January 2013 and May 2014 (Cohort 1). Next, we retrospectively investigated additional AEs that occurred before and after Cohort 1 within the period June 2012 and December 2014 among 1482 patients (Cohort 2). RESULTS: Of the 2578 patients who underwent PC examinations from both cohorts, 74 AEs occurred among 61 patients (2.37%). The main AEs were residual parylene coating in 25 events (0.97%), PC-induced small bowel obstruction, suspicious of impaction, in 23 events (0.89%), and CE retention even after patency confirmation in 10 events (0.39%). Residual parylene coating was significantly associated with Crohn's disease (P < 0.01). Small bowel obstruction was significantly associated with physicians with less than 1 year of experience handling the PC and previous history of postprandial abdominal pain (P < 0.01 and P < 0.03, respectively). CE retention was ascribed to erroneous judgment of PC localization in all cases. CONCLUSIONS: This large-scale multicenter study provides evidence supporting the safety and efficiency of a PC to preclude CE retention. Accurate PC localization in patients without excretion and confirmation of previous history of postprandial abdominal pain before PC examinations is warranted (UMIN000010513).

Successful Management of Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhagic Shock Due to Ruptured Hepatocellular Carcinoma.

A 68-year-old man was transferred to our hospital because of sudden right costal pain with unmeasurable hypotension. Ultrasonography revealed possible hemorrhagic shock due to ruptured hepatocellular carcinoma (HCC). As the patient was not hemodynamically stable after primary treatment, resuscitative endovascular balloon occlusion of the aorta (REBOA) was performed, and hemodynamic stability was then achieved. Contrast-enhanced computed tomography confirmed the diagnosis. Transcatheter artery embolization with gelatin sponge particles and coils eliminated the extravasation. The patient was discharged on day 36 post-procedure. Our observations suggest that REBOA may help achieve hemodynamic stability in cases of ruptured HCC.

Recovery of antimicrobial susceptibility in methicillin-resistant Staphylococcus aureus (MRSA): a retrospective, epidemiological analysis in a secondary care hospital, Sapporo, Japan.

Anti-methicillin-resistant Staphylococcus aureus (MRSA) drugs are critical final options for treating MRSA infection. This study investigated the percentage of all S. aureus isolates that are resistant to methicillin and also MRSA susceptibility to other antimicrobial agents in the JR Sapporo Hospital inpatient service. The inpatient service MRSA percentages for Japan, Hokkaido, and JR Sapporo Hospital from 2010-2019 were compared, exploring the annual rate of change in the MRSA percentage. We also investigated the antimicrobial use density (AUD) and its relationship with MRSA antimicrobial susceptibility in the JR Sapporo Hospital during 2019. The MRSA percentage in JR Sapporo Hospital was 61.5% (95% CI [52.6-69.7]) in 2010 but was only 51.6% (95% CI [41.6-61.5]) in 2019, which is a 1.43% (95% CI [0.42-2.43]) annual decrease (p = 0.05). Regarding the MRSA antimicrobial susceptibility rate in JR Sapporo Hospital, the highest rates of annual increase were seen for minocycline (3.11% (95% CI [2.25-3.94])) followed by fosfomycin (2.85% (95% CI [1.83-3.85])). Positive correlations with the AUD of anti-MRSA drugs were identified for susceptibility to erythromycin (p < 0.01), clindamycin (p = 0.002), and levofloxacin (p = 0.0005). A recovery of MRSA antimicrobial susceptibility was observed in our antibiogram dataset. Our study supports the potential for appropriate antimicrobial agent use in reviving MRSA antimicrobial susceptibility.

Transitional Changes in the Prevalence of Dental Caries in Children and Preventive Strategies: A Review of Nationwide Annual Surveys in Japan.

PURPOSE: To elucidate the efficacy of strategies for preventing dental caries in Japanese children by examining trends over time in the prevalence of dental caries, the number of decayed, missing, or filled teeth (the DMFT index), and their association with factors affecting oral hygiene. MATERIALS AND METHODS: Several national surveys performed between 1955 and 2015 were reviewed. The prevalence of dental caries in children aged 5-15 years, the DMFT index in children aged 9 or 14 years, individual consumption of added sugars and snacks, the number of dentists in Japan, and the percentage of children who received fluoride varnish were analysed. Additionally, the relative poverty rate among Japanese children was assessed. RESULTS: The prevalence of caries and the DMFT index in Japanese children reflected the trend of individual added-sugar consumption from 1955 to 2015, and also seemed to decrease inversely with the number of dentists and the percentage of children who had received fluoride varnish since 1969. However, there seemed to be no relation to the relative poverty rate. CONCLUSION: The main preventive strategies for caries in Japan are to reduce sugar intake and educate school children and their caregivers about oral hygiene.

Immune status of representative infectious diseases among Japanese female university students.

OBJECTIVE: To elucidate the immune status of representative infectious diseases among Japanese youth, we retrospectively investigated serum antibody levels in university students, partly comparing these to immunization records and infectious disease histories confirmed by the maternal and child health (MCH) handbooks. MATERIALS AND METHODS: In total, 168 Japanese female university students, aged 20-21 years, were included. Data were collected from examinations of antibody titers against measles, rubella, varicella-zoster (VZ), mumps, and hepatitis B (HB) and C (HC) viruses, and from QuantiFERON®-TB Gold tests, between 2011 and 2015. Records of immunization and infectious disease histories were available from MCH handbooks for students who agreed with the use of their data for this study (n=23). RESULTS: All students had positive antibodies, detected by enzyme immunoassay (EIA), against measles, rubella, VZ, and mumps; however, seroprevalences within the range of seroprotective antibody levels were 38.1% (64/168), 67.9% (114/168), 95.9% (141/147), and 89.8% (132/147), respectively. The students had probably not been infected with HB, HC, or tuberculosis at the time of the examinations. DISCUSSION: The study indicated that a two-dose vaccine for measles and rubella (MR) might not be sufficient to produce antibodies at seroprotective levels. Therefore, we propose that health care workers, including students, should receive an additional MR vaccine, even if they have received two doses of MR vaccine or if they have unknown histories of immunizations or infectious diseases. Further investigations in these areas will be needed.

Prevalence of lesbian, gay, bisexual, and transgender among Japanese university students: a single institution survey.

OBJECTIVE: To elucidate the prevalence of lesbian, gay, bisexual, and transgender (LGBT) among Japanese youth, we conducted a survey research that targeted university students. MATERIALS AND METHODS: Participants were first-year students (n=1597) at Ibaraki University, Japan (Phase 1 study) or second- to fourth-year students (n=944) at the university who were randomly preferred in the survey (Phase 2 study). Surveys measured gender identity and sexual orientation, partly using the gender identity scale (GIS). RESULTS: The prevalence of LGBT youth among university students were 2.7%, 0.5%, 5.3%, and 0.8% (Phase 1 study) or 1.4% (Phase 2 study), respectively. The GIS scores of the transgender group were significantly lower than those of the female, male, and LGB groups (p<0.01). DISCUSSION: This is the first to clarify the prevalence of LGBT among youth in Japan. It has been suggested that such individuals in Japan, as in other countries, are at risk for physical and mental health concerns, thereby necessitating social and medical intervention. Further investigation in these areas will be needed.

Japanese university students' views on lesbian, gay, bisexual, and transgender individuals based on previous encounters.

OBJECTIVE: To elucidate the acceptability of sexual minorities according to Japanese youth, we conducted a survey targeting university students. METHODS: Participants were second- to fourth-year students (n=945) at Ibaraki University, Japan, who were randomly chosen for the survey to measure their attitudes toward lesbian, gay, bisexual, and transgender (LGBT) individuals. We divided the respondents into two groups: one group who had encounters with LGBT people, and one group with no such experience. Chi-square tests were used to compare responses between the groups. RESULTS: More than 60% of the students considered LGBT people to be acceptable; the group with prior encounters had greater levels of acceptance compared to the group without such encounters. CONCLUSION: This is the first study to clarify the acceptability of sexual minorities among university students in Japan. Our data suggested that having contact with LGBT people in school life may help build an inclusive educational system.

Late, Late-Onset Group B Streptococcus Cellulitis With Bacteremia.

Group B streptococcus (GBS) infection remains a leading cause of serious neonatal and early infantile infection. As the infection often presents with nonspecific symptoms, and is associated with underlying bacteremia, prompt investigation and treatment is required. We report a case of late, late-onset GBS infection with bacteremia in a 94-day-old boy experiencing cellulitis of the left hand. Although late-onset disease or late, late-onset disease has been reported to be common among infants with underlying conditions such as premature birth, immunocompromised status, trauma, or among those using medical devices, no such underlying medical condition predisposed this infant to invasive GBS infection. Recent reports including the present case underscore the risk of GBS infection among previously healthy infants beyond the neonatal period. Thus, clinicians should especially be aware of unusual presentations of GBS invasive disease with bacteremia.

Bleeding due to acquired hemophilia A in acute pancreatitis: a case report.

Acquired hemophilia A leads to severe bleeding and is known to be related to many underlying diseases; however, it has not been reported to occur as a complication of pancreatitis. We present a case of acquired hemophilia A secondary to severe acute pancreatitis. A 76-year-old female developed a hematoma in the lower leg muscle while being treated for severe acute pancreatitis. Blood tests revealed prolonged activated partial thromboplastin time (APTT) and the presence of an autoantibody to factor VIII. The bleeding diathesis was successfully controlled by immunosuppressive therapy. This case highlights the need for careful differential diagnosis for successful management of bleeding disorders as complications of pancreatitis.

Successful treatment of short stature with growth hormone replacement therapy in a patient with anorexia nervosa.

A 19-year-old woman visited our outpatient clinic requesting treatment for short stature. She had been repeatedly hospitalized at a psychiatric unit and was subsequently diagnosed with anorexia nervosa (AN). She was 139.3 cm (-3.6 SD) tall and weighed 25.5 kg (23% lower than standard weight). She had primary amenorrhea and her bone age (BA) was 11.8 years. She had low insulin-like growth factor (IGF)-I (80 ng/mL) and a basal growth hormone (GH) level of 1.47 ng/mL. Treatment with recombinant GH was initiated. At 22 years of age, she was 152.2 cm (-1.1 SD) tall and weighed 39.7 kg. As she had shown a favorable response to GH treatment, therapy was discontinued. We suggest that it is worthwhile treating AN patients with GH replacement therapy for short stature, once low IGF-I levels without GH resistance, delayed puberty, delay in BA, and nutritional stabilization are taken into consideration.

Improved underpants to reduce toileting problems in patients with poor standing balance.

[Purpose] We developed and assessed improved underpants allowing patients to easily and completely open the crotch by pulling upward a string on the back of the underpants while seated. [Subjects and Methods] Healthy subjects tested commercial open-crotch underpants for disabled people and our improved open-crotch underpants by opening the crotch while seated. Measurement parameters included the percentage of crotch opening and the degree of genital or anal exposure before and after opening the crotch, as well as fit. The percentage of crotch opening and the degree of genital or anal exposure were recorded with a digital camera, and fit was determined with a visual analog scale. The measurements for both types of underpants were then compared. [Results] The commercial underpants for disabled people allowed opening of the crotch while seated, but the exposure of the genital and anal areas was insufficient to allow waste elimination. The improved underpants allowed sufficient opening of the crotch while seated and adequately exposed the genital and anal areas. The fit score of the improved underpants was significantly better than that of the commercial underpants. [Conclusion] The improved open-crotch underpants may allow for more effective opening of the crotch while seated than commercial open-crotch underpants for disabled people.

Approaches for improving the toileting problems of hemiplegic stroke patients with poor standing balance.

[Purpose] Our objective was to evaluate the residual dynamic and static functionality in the sitting position of hemiplegic stroke patients who require help to pull their lower garments up and down during toileting. [Subjects and Methods] The subjects were 11 hemiplegic patients. We gathered data on the patients' motor paralysis, sensory capacity, lower extremity muscle strength, trunk control, ability to roll and sit up from a lying position, sitting balance, and ability to pull the lower garments up and down. We then compared 2 groups: those able to pull the lower garments up and down independently while standing (the "independent group"), and those who were unable to do so (the "non-independent group"). [Results] Though the non-independent group had severely and significantly reduced trunk control and abilities as a whole, there was no significant difference from the independent group in static and dynamic sitting balance. [Conclusion] We conclude that, to enable hemiplegic patients with poor standing balance to pull their lower garments up and down, it is necessary to do these maneuvers in a sitting, rather than a standing, position, or to develop garments that are easier to put on and take off.

Protective effects of influenza A (H1N1) pandemic 2009 vaccination against the onset of influenza-like illness and asthma exacerbation in Japanese children.

BACKGROUND: Vaccination against influenza A(H1N1)pdm09 in Japan started in October 2009. Children with asthma are considered as a high-risk group and are recommended to preferentially receive the vaccine. OBJECTIVE: To identify the clinical effects of vaccination in Japanese children with and without asthma. METHODS: We conducted a cross-sectional, questionnaire-based survey to compare vaccination rates, vaccine effectiveness against physician-diagnosed influenza A infection (PDIA), and consecutive asthma exacerbations between children with and without asthma. RESULTS: Of the 460 children included in this study, those with asthma had higher vaccination rates (46.5%, 67/144) than those without asthma (30.4%, 96/316). Influenza A infections were diagnosed in 28 of 163 vaccinated children (17.2%) compared to 164 of 297 unvaccinated children (55.2%, p < 0.001). Comparison of positive influenza diagnosis rates between vaccinated and unvaccinated children with and without asthma showed that unvaccinated children with asthma had an elevated odds ratio (13.235; 95% confidence interval [CI], 5.564-32.134) and that treatment for asthma exacerbations was needed in a larger proportion of unvaccinated children. Vaccine effectiveness against PDIA was 87% (95% CI, 78-93%) overall, 92% (95% CI, 81-96%) in children with asthma and 81% (95% CI, 63-91%) in children without asthma, respectively. CONCLUSIONS: The administration of an inactivated, split-virus, non-adjuvanted monovalent A(H1N1)pdm09 vaccine during the pandemic period reduced the number of physician-diagnosed influenza A infections and asthma exacerbations in children with asthma. Therefore, we strongly recommend that high-risk children with a history of asthma receive vaccines during pandemics.

Effectiveness and clinical results of endoscopic management of sigmoid volvulus using unsedated water-immersion colonoscopy.

BACKGROUND AND AIM: Although intestinal obstruction as a result of sigmoid volvulus (SV) may be successfully resolved using endoscopic detorsion, surgical treatment remains the main therapeutic strategy. We evaluated the endoscopic detorsion procedure using unsedated water-immersion colonoscopy for the treatment of SV. METHODS: A retrospective chart review was conducted on the clinical background and prognosis of 21 SV patients who underwent 71 endoscopic detorsion procedures using unsedated, water-immersion colonoscopy. RESULTS: In all, 14 (67%) male and seven (33%) female patients, with a mean age of 73 years (range, 54-95 years) were enrolled; 86% were >70 years of age. Among these patients, 90% had a background of key predisposing factors. In the 21 patients, endoscopic detorsion was successfully done using unsedated water-immersion colonoscopy. SV recurred in 10 patients at a median of 180 days. Endoscopic detorsion for recurrent SV was successfully achieved in all cases, and none of the secondary cases became severe. Only male patients were observed to experience three or more recurrent episodes of SV. CONCLUSIONS: SV occurred most commonly in elderly patients with a surgical risk. Our experience suggests that conservative endoscopic treatment using unsedated water-immersion colonoscopy is a safe, reasonable, conservative endoscopic approach for elderly patients in the absence of necrotic findings. We currently use this procedure in most of our cases.

Successful treatment of ileocolic intussusception with air enema reduction in an adult patient.

Intussusception is a rare condition in adults, representing only 1% of all bowel obstructions. In adult cases, operative explorations are recommended to treat the bowel obstruction and to diagnose underlying diseases. The objective of the current case report was to describe the successful treatment of ileocolic intussusception with air enema reduction in an adult patient. A previously healthy 21-year-old woman had a 20-hour history of colicky abdominal pain and vomiting and was diagnosed as having idiopathic ileocolic intussusception by abdominal computed tomography. We treated the patient with air enema reduction under fluoroscopic guidance instead of an operative procedure. She received oxygen and intravenous midazolam to provide some degree of pain relief. Air was carefully pumped manually into the rectum, and the air pressure was monitored with a manometer. Because of air leakage from the rectum through the void to the outside the body, we continued to provide air to maintain the air pressure between 40 and 60 mm Hg. Three minutes after initiation of the air enema, when the patient experienced increasing abdominal pain and vomiting, the pressure was temporarily increased to greater than 100 mm Hg, and the air reached the terminal ileum. We considered the reduction successful and confirmed it with an abdominal ultrasound examination. We believe that air enema reduction is effective for treating idiopathic intussusception within 24 hours of symptom onset in young, previously healthy adult patients.

Hemophagocytic Syndrome Associated with Mycoplasma pneumoniae Pneumonia.

Mycoplasma pneumoniae (Mp) sometimes causes immunological complications in children. We present a rare case of hemophagocytic syndrome (HPS) caused by Mp in a previously healthy 7-year-old Japanese girl. A chest radiograph obtained to evaluate the source of her fever showed infiltration in the lower right lung with mild splenomegaly. We could diagnose the patient with HPS on the basis of the hemophagocytic-lymphohistiocytosis- (HLH) 2004 criteria. She met the criteria for fever, splenomegaly, neutrophil count (<1,000/ µ L), platelet count (<10.0 × 10(4)/ µ L), fasting triglyceride level (>265 mg/dL), and ferritin level (>500 ng/mL). Furthermore, a peripheral blood smear showed an increased number of monocytes/macrophages with erythrophagocytosis. Treatment with clarithromycin and prednisolone, which was initiated soon after the diagnosis, was successful. Mp infection might partly progress to HPS in certain conditions. Clinicians should be aware of HPS caused by Mp and start appropriate treatment as soon as possible if the disease is suspected.

A case of acute hepatitis B related to previous gynecological surgery in Japan.

A 41-year-old woman became ill with acute hepatitis B after gynecological surgery performed by a surgeon who was hepatitis B surface antigen positive. The surgeon was positive for hepatitis B e antigen, and HBV DNA concentrations in the serum, saliva, and sweat of the surgeon were very high. HBV genotype and partial HBV DNA sequences from the HBV-infected surgeon were identical to those in the HBV-infected patient. Extensive research by the committee including infection control and prevention specialists judged the source of infection to be a surgeon infected with HBV. Transmission of HBV from a healthcare worker to patients who are not immune to HBV can actually happen. This case report illustrates the importance of a stringent policy of a nationwide HBV universal vaccination program.