Search

Purpose: To investigate the morphological characteristics and operative outcomes of acute type A aortic dissection (ATAAD) in patients with aortic arch variants., Methods: Of 616 patients with ATAAD, 97 (15.7%) had aortic arch variants, including bovine aortic arch (BAA, n = 66), isolated left vertebral artery (ILVA, n = 25), and aberrant subclavian artery (ASA, n = 6). The characteristics and outcomes were compared between the normal branching group (control, n = 519) and the total/individual arch variant groups., Results: Compared to the control group, arch entry was more prevalent in the BAA (18.5% vs. 31.8%) and ILVA groups (44%) (both, P < 0.05), and right common carotid arterial occlusion was less common in the arch variant group (6.7% vs. 0%, P = 0.017). The in-hospital mortality (9.2% vs. 9.3%), new-onset stroke (7.3% vs. 7.2%), and 5-year survival (81.7% vs. 78.8%) did not differ markedly between the control and arch variant groups. Arch repair was performed in 28.9% (28/97) of the arch variant group using 3-4 vessel antegrade cerebral perfusion, with 3.8% in-hospital mortality and a 15.4% stroke rate, which were comparable to those of the control group., Conclusions: Aortic arch variants may influence tear location and involvement of the supra-arch vessels but may not affect postoperative outcomes., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Objective: We investigated the effect of the pandemic on neurological hospitalizations and complications associated with severe acute respiratory syndrome coronavirus 2 infection or vaccinations., Methods: We retrospectively analyzed data of patients hospitalized in our neurology division from 1 April 2019 to 31 March 2022 as the opt-out study. We classified the neurological diseases into nine subgroups, evaluated changes of neurological disease characteristics, and analyzed patients hospitalized with the complications from severe acute respiratory syndrome coronavirus 2 infection or after the coronavirus disease 2019 vaccination over three eras based on the pandemic stages: (1) pre-pandemic, (2) during the pandemic but before vaccines, and (3) during the pandemic with vaccines., Results: Overall, 1756 patients were included in the analyses. The patient characteristics significantly changed throughout the pandemic ( p  < 0.01). Although the number of autoimmune cases did not change throughout the pandemic ( p  = 0.53), that of psychological cases and that of unknown cases were significantly changed ( p  < 0.05, p  < 0.01). There were four infectious cases and 11 cases following vaccination from 1 April 2020 to 31 March 2022. The 11 postvaccination cases involved 10 kinds of neurological diseases., Conclusions: The neurological characteristics significantly changed throughout the pandemic and there were diverse neurological complications following vaccinations., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Competency in the use of information science and technology (IST) is essential for medical students. This study identified learning objectives and competencies that correspond with low self-assessment related to use of IST and factors that improve such self-assessment among medical students., Methods: A questionnaire was administered to sixth-year medical students across 82 medical schools in Japan between November 2022 and February 2023., Results: Three learning objectives were identified as difficult for the students to achieve: (1) provide an overview of the regulations, laws, and guidelines related to IST in medicine; (2) discuss ethical issues, such as social disparities caused by the digital divide that may arise in the use of IST in medicine; and (3) understand IST related to medical care. Further, problem-based learning, engaging with IST beyond class, and learning approach impacted the students' acquisition of competencies related to IST. Furthermore, it was recognized that the competencies required by medical students may change over the course of an updated medical school curriculum., Conclusions: It is important for medical students to recognize the significance of learning, establishing active learning methods, and gaining experience in practically applying these competencies., (© 2024. The Author(s).)

Spontaneous intracerebral hemorrhage (SICH) remains a devastating form of stroke. Prior use of antiplatelets or warfarin before SICH is associated with poor outcomes, but the effects of direct oral anticoagulants (DOACs) remain unclear. This study aimed to clarify trends in prior antithrombotic use and to assess the associations between prior use of antithrombotics and in-hospital mortality using a multicenter prospective registry in Japan. In total, 1085 patients were analyzed. Prior antithrombotic medication included antiplatelets in 14.2%, oral anticoagulants in 8.1%, and both in 1.8%. Prior warfarin use was significantly associated with in-hospital mortality (odds ratio [OR] 5.50, 95% confidence interval [CI] 1.30-23.26, P < 0.05) compared to no prior antithrombotic use. No such association was evident between prior DOAC use and no prior antithrombotic use (OR 1.34, 95% CI 0.44-4.05, P = 0.606). Concomitant use of antiplatelets and warfarin further increased the in-hospital mortality rate (37.5%) compared to warfarin alone (17.2%), but no such association was found for antiplatelets plus DOACs (8.3%) compared to DOACs alone (11.9%). Prior use of warfarin remains an independent risk factor for in-hospital mortality after SICH in the era of DOACs. Further strategies are warranted to reduce SICH among patients receiving oral anticoagulants and to prevent serious outcomes., (© 2024. The Author(s).)

We evaluated the effectiveness of a mobile health (mHealth) intervention for diabetic kidney disease patients by conducting a 12-month randomized controlled trial among 126 type 2 diabetes mellitus patients with moderately increased albuminuria (urinary albumin-to-creatinine ratio (UACR): 30-299 mg/g creatinine) recruited from eight clinical sites in Japan. Using a Theory of Planned Behavior (TPB) behavior change theory framework, the intervention provides patients detailed information in order to improve patient control over exercise and dietary behaviors. In addition to standard care, the intervention group received DialBetesPlus, a self-management support system allowing patients to monitor exercise, blood glucose, diet, blood pressure, and body weight via a smartphone application. The primary outcome, change in UACR after 12 months (used as a surrogate measure of renal function), was 28.8% better than the control group's change (P = 0.029). Secondary outcomes also improved in the intervention group, including a 0.32-point better change in HbA1c percentage (P = 0.041). These improvements persisted when models were adjusted to account for the impacts of coadministration of drugs targeting albuminuria (GLP-1 receptor agonists, SGLT-2 inhibitors, ACE inhibitors, and ARBs) (UACR: -32.3% [95% CI: -49.2%, -9.8%] between-group difference in change, P = 0.008). Exploratory multivariate regression analysis suggests that the improvements were primarily due to levels of exercise. This is the first trial to show that a lifestyle intervention via mHealth achieved a clinically-significant improvement in moderately increased albuminuria., (© 2024. The Author(s).)

Objectives: The purpose of this study was to evaluate the effect of decalcification and existence of stent at the aortic annulus on mitral annular motion after surgery., Methods: Patients receiving Inspiris (Edwards, CA, USA, n = 117), Intuity (Edwards, n = 36), Perceval (Corcym, London, UK, n = 36), Evolut (Medtronics, MN, USA, n = 81) and Sapien 3 (Edwards, n = 250) were included in the study. Mitral annular motion was evaluated by E', using tissue doppler imaging., Results: After surgery, a significant increase in E' was observed in patients receiving Inspiris (Before: 4.2 ± 1.21 cm/s vs. Discharge: 5.0 ± 1.23 cm/s, p < 0.001). Mid-term echocardiogram performed at 11.8 ± 2.2 months after the surgery, showed a significant increase in E' in patients receiving Inspiris (Before: 4.2 ± 1.21 cm/s vs. Mid-term: 5.2 ± 1.20 cm/s, p < 0.001) and Perceval (Before: 3.9 ± 1.34 cm/s vs. Mid-term: 4.5 ± 1.24 cm/s, p = 0.008). Univariable analysis showed a higher increase in E' in patients with decalcified annulus compared to those without decalcified annulus (Decalcification: 0.15 ± 1.321 cm/s vs. No Decalcification: 0.66 ± 1.420 cm/s, p < 0.001). Multivariable analysis showed that balloon-expandable stent (β = - 0.6960, p < 0.001) and self-expanding stent (r = - 0.3592, p = 0.042) were independent limiting factors for an increase in E' at discharge. However, balloon-expandable stent (β = - 0.8382, p < 0.001), and not self-expanding stent (β = - 0.3682, p = 0.089), was a remaining independent factor associated with E' at mid-term follow-up., Conclusions: Decalcification was associated with improvement in E' after surgery. Balloon-expandable stent was an independent limiting factor for improvement in E' up to 1 year after the surgery, while self-expanding stent was not a significant factor after 1 year., (© 2023. The Japanese Society for Artificial Organs.)

Background: Donors bravely donate their kidneys because they expect that living donor kidney transplantation (LKT) confers benefits to recipients. However, the magnitude of the survival benefit of LKT is uncertain., Methods: This prospective cohort study used two Japanese nationwide databases for dialysis and kidney transplantation and included 862 LKT recipients and 285,242 hemodialysis (HD) patients in the main model and 5299 LKT recipients and 151,074 HD patients in the supplementary model. We employed time-dependent model in the main model and assessed the hazard ratio and the difference in the restricted mean survival time (RMST) between LKT recipients and HD patients. In the main analysis of the main model (LKT, N = 675; HD, N = 675), we matched LKT recipients with HD patients by age, sex, dialysis vintage, and cause of renal failure and excluded HD patients with dementia or performance status grades 2, 3, or 4., Results: The median observational period was 8.00 (IQR 3.58-8.00) years. LKT was significantly associated with a lower risk of mortality (hazard ratios (95% confidence interval (CI)), 0.50 (0.35-0.72)) and an increase in life expectancy (7-year RMST differences (95% CI), 0.48 (0.35-0.60) years) compared with HD. In subgroup analysis, the survival benefit of LKT was greater in female patients than in male patients in the Cox model; whereas older patients gained longer life expectancy compared with younger patients., Conclusions: LKT was associated with better survival benefits than HD, and the estimated increase in life expectancy was 0.48 years for 7 years., (© 2023. The Author(s).)

Background: Recent studies about inter-reporter differences and patient-reported outcomes (PROs) in childhood cancer from Western countries showed that caregiver proxy reports tend to overestimate symptom burdens in comparison with children's self-reports. However, the results from Western countries may not be generalizable to Asian countries., Methods: This paper is a secondary analysis of a validation study of the Japanese pediatric version of the Memorial Symptom Assessment Scale including 88 dyads of children aged 7-12 years and 74 dyads of children aged 13-18 years and their caregivers. The study assessed the inter-reporter differences of eight and 31 symptom burdens calculated as symptom scores in children aged 7-12 years and 13-18 years, respectively, and the association between inter-reporter differences and the characteristics of children and caregivers., Results: The majority of children and caregivers scored equally at the dyadic level for almost all symptoms. However, 37.5% of symptoms in children aged 7-12 years and 10.0% of symptoms in children aged 13-18 years showed significant inter-reporter differences, suggesting a general tendency of caregivers to underestimate their children's symptom burden. The caregiver's age was the characteristic most frequently associated with magnitude of inter-reporter differences., Conclusions: Caregiver proxy reports may be a reliable source of PROs in Japanese children with cancer, as self-reported and caregiver proxy-reported symptom burdens were generally concordant. However, as some significant inter-reporter differences were observed, an effort should be made within the medical community to evaluate the parent-child relationship to minimize inter-reporter differences and achieve better symptom management., (© 2024 Japan Pediatric Society.)

Background/aims: Colorectal adenomas are precursor lesions of globally increasing colorectal cancer. Hence, a high adenoma detection rate in colonoscopy is pivotal. We investigated the clinical impact of stratified colonoscopy observation time combined with observation time/intubation time ratio on the detection of colorectal adenomas., Materials and Methods: We conducted a single-center retrospective study including 369 consecutive patients who underwent colonoscopy following fecal immunochemical tests between May 2021 and April 2022. The primary outcome measure was the impact of the stratified observation time and observation time/ intubation time ratio (category 1: <6.0 minutes and <1.0, category 2: <6.0 minutes and ≥1.0, category 3: ≥6.0 minutes and <1.0, and category 4: ≥6.0 minutes and ≥1.0) on adenoma detection rate., Results: Cecum intubation was obtained in 367 patients (99.5%). Adenomas were detected in 226 patients (61.2%). From the univariate analysis, age ≥53 years, habitual alcohol intake, colonoscopy attachment (+), and observation time with observation time/intubation time ratio categories 3 and 4 were determined as significant factors for adenoma detection rate. From the logistic regression analysis, age ≥ 53 years (odds ratio: 4.86, 95% CI: 2.25-10.52), habitual alcohol intake (odds ratio: 2.26, 95% CI: 1.33-3.82), category 3 (odds ratio: 3.66, 95% CI: 1.81-7.45), and category 4 (odds ratio: 5.60, 95% CI: 2.92-10.73) were significant factors for adenoma detection rate., Conclusion: We propose the observation time with observation time/intubation time ratio combined benchmark (with categories' thresholds based on observation time >6 minutes and scope withdrawal time exceeding intubation time [observation time/intubation time ratio > 1]) as a novel colonoscopy quality indicator. These findings represent an important educational message for endoscopists.

Background: Reduced or delayed medical follow-ups have been reported during the COVID-19 pandemic, which may lead to worsening clinical outcomes for patients with diabetes. The Japanese government granted special permission for medical institutions to use telephone consultations and other remote communication modes during the COVID-19 pandemic., Objective: We aimed to evaluate changes in the frequency of outpatient consultations, glycemic control, and renal function among patients with type 2 diabetes before and during the COVID-19 pandemic., Methods: This is a retrospective single-cohort study conducted in Tokyo, Japan, analyzing results for 3035 patients who visited the hospital regularly. We compared the frequency of outpatient consultations attended (both in person and via telemedicine phone consultation), glycated hemoglobin A 1c (HbA 1c ), and estimated glomerular filtration rate (eGFR) among patients with type 2 diabetes mellitus during the 6 months from April 2020 to September 2020 (ie, during the COVID-19 pandemic) with those during the same period of the previous year, 2019, using Wilcoxon signed rank tests. We conducted a multivariate logistic regression analysis to identify factors related to the changes in glycemic control and eGFR. We also compared the changes in HbA 1c and eGFR from 2019 to 2020 among telemedicine users and telemedicine nonusers using difference-in-differences design., Results: The overall median number of outpatient consultations attended decreased significantly from 3 (IQR 2-3) in 2019 to 2 (IQR 2-3) in 2020 (P<.001). Median HbA 1c levels deteriorated, though not to a clinically significant degree (6.90%, IQR 6.47%-7.39% vs 6.95%, IQR 6.47%-7.40%; P<.001). The decline in median eGFR was greater during the year 2019-2020 compared to the year 2018-2019 (-0.9 vs -0.5 mL/min/1.73 m2; P=.01). Changes in HbA 1c and eGFR did not differ between patients who used telemedicine phone consultations and those who did not. Age and HbA 1c level before the pandemic were positive predictors of worsening glycemic control during the COVID-19 pandemic, whereas the number of outpatient consultations attended was identified as a negative predictor of worsening glycemic control during the pandemic., Conclusions: The COVID-19 pandemic resulted in reduced attendance of outpatient consultations among patients with type 2 diabetes, and these patients also experienced deterioration in kidney function. Difference in consultation modality (in person or by phone) did not affect glycemic control and renal progression of the patients., (©Akiko Sankoda, Yugo Nagae, Kayo Waki, Wei Thing Sze, Koji Oba, Makiko Mieno, Masaomi Nangaku, Toshimasa Yamauchi, Kazuhiko Ohe. Originally published in JMIR Diabetes (https://diabetes.jmir.org), 21.11.2023.)

Importance: Chronic kidney disease (low estimated glomerular filtration rate [eGFR] or albuminuria) affects approximately 14% of adults in the US., Objective: To evaluate associations of lower eGFR based on creatinine alone, lower eGFR based on creatinine combined with cystatin C, and more severe albuminuria with adverse kidney outcomes, cardiovascular outcomes, and other health outcomes., Design, Setting, and Participants: Individual-participant data meta-analysis of 27 503 140 individuals from 114 global cohorts (eGFR based on creatinine alone) and 720 736 individuals from 20 cohorts (eGFR based on creatinine and cystatin C) and 9 067 753 individuals from 114 cohorts (albuminuria) from 1980 to 2021., Exposures: The Chronic Kidney Disease Epidemiology Collaboration 2021 equations for eGFR based on creatinine alone and eGFR based on creatinine and cystatin C; and albuminuria estimated as urine albumin to creatinine ratio (UACR)., Main Outcomes and Measures: The risk of kidney failure requiring replacement therapy, all-cause mortality, cardiovascular mortality, acute kidney injury, any hospitalization, coronary heart disease, stroke, heart failure, atrial fibrillation, and peripheral artery disease. The analyses were performed within each cohort and summarized with random-effects meta-analyses., Results: Within the population using eGFR based on creatinine alone (mean age, 54 years [SD, 17 years]; 51% were women; mean follow-up time, 4.8 years [SD, 3.3 years]), the mean eGFR was 90 mL/min/1.73 m2 (SD, 22 mL/min/1.73 m2) and the median UACR was 11 mg/g (IQR, 8-16 mg/g). Within the population using eGFR based on creatinine and cystatin C (mean age, 59 years [SD, 12 years]; 53% were women; mean follow-up time, 10.8 years [SD, 4.1 years]), the mean eGFR was 88 mL/min/1.73 m2 (SD, 22 mL/min/1.73 m2) and the median UACR was 9 mg/g (IQR, 6-18 mg/g). Lower eGFR (whether based on creatinine alone or based on creatinine and cystatin C) and higher UACR were each significantly associated with higher risk for each of the 10 adverse outcomes, including those in the mildest categories of chronic kidney disease. For example, among people with a UACR less than 10 mg/g, an eGFR of 45 to 59 mL/min/1.73 m2 based on creatinine alone was associated with significantly higher hospitalization rates compared with an eGFR of 90 to 104 mL/min/1.73 m2 (adjusted hazard ratio, 1.3 [95% CI, 1.2-1.3]; 161 vs 79 events per 1000 person-years; excess absolute risk, 22 events per 1000 person-years [95% CI, 19-25 events per 1000 person-years])., Conclusions and Relevance: In this retrospective analysis of 114 cohorts, lower eGFR based on creatinine alone, lower eGFR based on creatinine and cystatin C, and more severe UACR were each associated with increased rates of 10 adverse outcomes, including adverse kidney outcomes, cardiovascular diseases, and hospitalizations.

Psoriasis is an immune-mediated chronic inflammatory disease that predominantly affects the skin and joints. Systemic therapies are required for patients with moderate-to-severe psoriasis, and biologics can provide significant symptomatic improvement. Computed tomography (CT) analysis is recommended before and after biologic therapy to exclude the possibility of comorbid infections and malignancies; incidental findings are often detected in asymptomatic patients. In this study, we analyzed the common incidental findings on CT in 227 patients with psoriasis on biologic therapy and 219 living-kidney transplant donors at our hospital. Incidental findings on CT were observed in 176 (77.5%) patients with psoriasis. The most common were fatty liver (82 patients, 36.1%), urolithiasis (54 patients, 23.8%), pulmonary lesions (47 patients, 20.7%), gallstones or postoperative gallstones (38 patients, 16.7%), liver cysts (36 patients, 15.9%), renal cysts (33 patients, 14.5%), and colonic diverticulum (22 patients, 9.7%), which were observed in 38 (17.4%), eight (3.7%), 68 (31.1%), 12 (5.5%), 58 (26.5%), 88 (40.2%), and 10 (4.6%) donors, respectively. The prevalence of fatty liver, urolithiasis, gallstones, and postoperative gallstones was significantly higher in patients with psoriasis. Multivariate logistic regression showed that psoriasis was a risk factor for fatty liver disease, urolithiasis, and gallstones. Currently, incidental findings on CT in patients with psoriasis have not been well studied. The results of this survey will lead to increased awareness of the incidental findings on CT as a complication of psoriasis., (© 2023 Japanese Dermatological Association.)

Background: High lipoprotein (a) level is an established cardiovascular risk, but its association with non-cardiovascular diseases, especially cancer, is controversial. Serum lipoprotein (a) levels vary widely by genetic backgrounds and are largely determined by the genetic variations of apolipoprotein (a) gene, LPA. In this study, we investigate the association between SNPs in LPA region and cancer incidence and mortality in Japanese., Methods: A genetic cohort study was conducted utilizing the data from 9923 participants in the Japan Public Health Center-based Prospective Study (JPHC Study). Twenty-five SNPs in the LPAL2-LPA region were selected from the genome-wide genotyped data. Cox regression analysis adjusted for the covariates and competing risks of death from other causes, were used to estimate the relative risk (hazard ratios (HR) with 95% confidence intervals (CI)) of overall and site-specific cancer incidence and mortality, for each SNP., Results: No significant association was found between SNPs in the LPAL2-LPA region and cancer incidence or mortality (overall/site-specific cancer). In men, however, HRs for stomach cancer incidence of 18SNPs were estimated higher than 1.5 (e.g., 2.15 for rs13202636, model free, 95%CI: 1.28-3.62) and those for stomach cancer mortality of 2SNPs (rs9365171, rs1367211) were estimated 2.13 (recessive, 95%CI:1.04-4.37) and 1.61 (additive, 95%CI: 1.00-2.59). Additionally, the minor allele for SNP rs3798220 showed increased death risk from colorectal cancer (CRC) in men (HR: 3.29, 95% CI:1.59 - 6.81) and decreased CRC incidence risk in women (HR: 0.46, 95%CI: 0.22-0.94). Minor allele carrier of any of 4SNPs could have risk of prostate cancer incidence (e.g., rs9365171 dominant, HR: 1.71, 95%CI: 1.06-2.77)., Conclusions: None of the 25 SNPs in the LPAL2-LPA region was found to be significantly associated with cancer incidence or mortality. Considering the possible association between SNPs in LPAL2-LPA region and colorectal, prostate and stomach cancer incidence or mortality, further analysis using different cohorts is warranted., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: To compare the risk of spontaneous preterm birth (SPTB) before 35 weeks in symptomatic and asymptomatic women with cervical shortening at 16-34 weeks under mid-trimester universal screening of cervical length (CL)., Method: Multicenter retrospective cohort study involving six secondary/tertiary perinatal centers was planned in 2016. Primary outcomes were SPTB before 35 weeks. In all, 407 women were analyzed using multivariable logistic regression analysis for predicting SPTB before 35 weeks while adjusting for presence/absence of uterine contraction, gestational weeks, vaginal bleeding, and CL classification (1-9, 10-14, 15-19, and 20-24 mm) at admission, the execution of cervical cerclage, and the presence/absence of past history of preterm delivery., Results: SPTB before 35 weeks of pregnancy occurred in 14.5%. Presence of uterine contraction was not an independent risk factor for SPTB before 35 weeks (adjusted odds ratio [aOR] 1.22, 95% confidence interval [CI] 0.67-2.20). CL of 1-9 mm, CL of 10-14 mm, and vaginal bleeding at admission were independent risk factors for SPTB before 35 weeks (aOR 5.35, 95% CI 2.11-13.6; aOR 2.79, 95% CI 1.12-6.98; and aOR 2.37, 95% CI 1.12-5.10, respectively)., Conclusion: In women with a cervical shortening at 16-34 weeks, presence of uterine contractions at admission may not be an independent risk factor for the occurrence of SPTB before 35 weeks., (© 2022 International Federation of Gynecology and Obstetrics.)

Introduction: This study aimed to retrospectively examine the drug survival of tumor necrosis factor (TNF)-alpha inhibitors and switched subsequent biologic agents after discontinuation of TNF inhibitors., Methods: This real-world setting study was conducted at a single academic center. We included patients who were treated with adalimumab (n = 111), certolizumab pegol (n = 12), and infliximab (n = 74) at Jichi Medical University Hospital from 1 January 2010 to 31 July 2021., Results: No significant differences were noted in drug survival between the three TNF inhibitors. The 10-year drug survival rate for adalimumab and infliximab was 14% and 18%, respectively. Of the patients who discontinued TNF inhibitors for any reason (n = 137), 105 chose biologics as their subsequent treatment. The subsequent biologics included 31 cases of TNF inhibitors (adalimumab in 20, certolizumab pegol in 1, and infliximab in 10), 19 of interleukin-12/23 inhibitor (ustekinumab), 42 of interleukin-17 inhibitors (secukinumab in 19, brodalumab in 9, and ixekizumab in 14) and 13 of interleukin-23 inhibitors (guselkumab in 11, risankizumab in 1, and tildrakizumab in 1). Cox proportional hazards analysis for the subsequent drugs in cases of discontinuation due to inadequate efficacy revealed that female sex was a predictor of drug discontinuation (hazard ratio 2.58, 95% confidence interval 1.17-5.70) and that taking interleukin-17 inhibitors rather than TNF inhibitors was a predictor of drug persistence (hazard ratio 0.37, 95% confidence interval 0.15-0.93)., Conclusions: Interleukin-17 inhibitors may be a favorable option for patients who need to switch from TNF inhibitors due to inadequate efficacy. However, this study is limited by the small number of cases and its retrospective design., (© 2023. The Author(s).)

Objective: This trial evaluated the superiority of intraoperative wound irrigation (IOWI) with aqueous povidone-iodine (PVP-I) compared with that with saline for reducing the incidence of surgical site infection (SSI)., Background: IOWI with aqueous PVP-I is recommended for the prevention of SSI by the World Health Organization and the Centers for Disease Control and Prevention, although the evidence level is low., Methods: This single institute in Japan, prospective, randomized, blinded-endpoint trial was conducted to assess the superiority of IOWI with aqueous PVP-I in comparison with IOWI with saline for reducing the incidence of SSI in clean-contaminated wounds after gastroenterological surgery. Patients 20 years or older were assessed for eligibility, and the eligible participants were randomized at a 1:1 ratio using a computer-generated block randomization. In the study group, IOWI was performed for 1 minute with 40 mL of aqueous 10% PVP-I before skin closure. In the control group, the procedure was performed with 100 mL of saline. Participants, assessors, and analysts were masked to the treatment allocation. The primary outcome was the incidence of incisional SSI in the intention-to-treat set., Results: Between June 2019 and March 2022, 941 patients were randomized to the study group (473 patients) or the control group (468 patients). The incidence of incisional SSI was 7.6% in the study group and 5.1% in the control group (risk difference 0.025, 95% CI -0.006 to 0.056; risk ratio 1.484, 95% CI 0.9 to 2.448; P =0.154)., Conclusion: The current recommendation of IOWI with aqueous PVP-I should be reconsidered., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: We investigated the efficacy of the Delirium Team Approach program for delirium prevention after cardiovascular surgery., Methods: We retrospectively investigated 256 patients who underwent cardiac or thoracic vascular surgery between May 2017 and May 2020. We compared the outcomes before and after implementation of the Delirium Team Approach program in December 2018. The program included the following components: (a) educational sessions for the medical team regarding delirium and its management, (b) review of preprinted physician orders for insomnia and agitation, and (c) routine screening for delirium. We investigated the early outcomes and effects of the Delirium Team Approach program on postoperative delirium., Results: The incidence of postoperative delirium significantly decreased from 53.3% to 37.0% after implementation of the Delirium Team Approach program (P = .008). Although no intergroup differences were observed in the rates of stroke and reexploration for bleeding, the length of intensive care unit stay and the overall length of postoperative hospital stay were shorter in the postintervention group. Hospital costs, excluding surgery, and the cost during intensive care unit stay were lower in the postintervention group. Multivariable analysis showed that the Delirium Team Approach program was associated with a reduction in postoperative delirium (odds ratio, 0.38; 95% confidence interval, 0.21-0.67; P = .001). Other predictors of delirium included age, dementia, chronic kidney disease, and intubation time. After risk adjustment using propensity score matching, the rate of postoperative delirium was lower in the postintervention group., Conclusions: Implementation of the Delirium Team Approach program was associated with a lower incidence of postoperative delirium in patients who underwent cardiovascular surgery., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Endoscopic balloon dilation (EBD) is an effective, minimally invasive treatment for Crohn's disease (CD) related intestinal strictures. However, restenosis frequently occurs and requires repetitive EBD or surgical resection. Since previous studies could not evaluate restenosis based on stricture diameter, factors affecting restenosis after EBD were unclear. This study aimed to identify these factors by precisely measuring the diameter of small intestinal strictures in patients with CD., Methods: This single-center retrospective study enrolled patients with CD with de novo small intestinal strictures who underwent two double-balloon enteroscopy sessions (EBD and follow-up) between January 2016 and October 2021. Clinical and endoscopic data were obtained from electronic medical records. A calibrated small-caliber-tip transparent hood was used to precisely measure stricture diameters. Multivariate analysis was performed to identify factors associated with restenosis., Results: Forty-eight patients (37 male) were analyzed. The total number of strictures detected decreased from 162 to 143. The mean diameter of all strictures and the narrowest stricture in each patient increased significantly from 8.6 to 9.8 mm and from 7.6 to 8.7 mm, respectively. Thirty-two (67%) patients developed endoscopic restenosis. Multivariate analysis showed that the presence of ulcers at the follow-up session was a risk factor for restenosis (odds ratio 9.4, p = 0.01). Patients with complete mucosal healing at both sessions ( n = 21) showed significant improvement in the narrowest stricture (+1.7 mm, p = 0.001)., Conclusions: Maintenance of complete mucosal healing is significantly associated with avoiding restenosis after EBD in CD-related small intestinal strictures., Competing Interests: Hironori Yamamoto has patents for the calibrated small‐caliber‐tip transparent hood. Hironori Yamamoto has patents for double‐balloon endoscopy and a consultant relationship with Fujifilm. Tomonori Yano and Hirotsugu Sakamoto have received research funding and honoraria from Fujifilm. No other authors have personal financial relationships with a commercial entity producing healthcare‐related products and/or services relevant to this article., (© 2023 The Authors. DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

The predominant histological subtype of breast mucinous carcinoma in older women is type B (hypercellular type), and, in younger women, it is type A (hypocellular type). The characteristics of mucinous carcinomas of the same histological subtype may differ between older and younger women. This study aims to systematically clarify the pathological/immunohistochemical features of mucinous carcinomas. A total of 21 surgical cases of mucinous carcinoma (type A/B: 9/12 cases) in the older group (≥65 years) and 16 cases (type A/B: 14/2 cases) in the younger group (≤55 years) (n = 37) were included. Gross cystic disease fluid protein-15 (GCDFP-15) and eight other markers were used for immunostaining. The GCDFP-15-positive rate in the older group was high regardless of the histological subtype (type A, 77.8%; type B, 91.7%). The GCDFP-15 positivity in the older group was significantly higher than that in the younger group (p < 0.001 for Allred score). Among type A, GCDFP-15 positivity was significantly higher in the older group than in the younger group (p = 0.042 for the Allred score and p = 0.007 for the positivity rate). The present results suggest that GCDFP-15 expression characterizes mucinous carcinomas in older women.

Rapid deployment valve has expanded surgical indication for high-risk patients with aortic stenosis despite its accommodated risk for conduction disorder (CD). The purpose of this study was to evaluate the degree of oversizing in association with postoperative CD. During June 2019 to September 2021, 25 patients underwent aortic valve replacement with Edwards INTUITY. Device size selection was evaluated intraoperatively using provided sizers. Oversizing was evaluated retrospectively by measuring the difference of the dimension of the annulus and left ventricular outflow tract (LVOT) compared to the dimensions of the device used by preoperative-computed tomography. Although there was no incidence of pacemaker implantation, seven patients (28.0%) experienced CD after surgery. There was no difference in device area and annulus area (CD: - 37 ± 22.7 mm 2 vs. no CD: - 56 ± 63.6 mm 2 , p = 0.47), and device circumference and annulus circumference (CD: - 4.4 ± 2.77 mm vs. no CD: - 6.9 ± 5.60 mm, p = 0.26) in patients with and without CD. However, there was a significant difference in area of the device skirt and sub-annular area at the LVOT (CD: 114 ± 28.4 mm 2 vs. no CD: - 8 ± 80.0 mm 2 , p < 0.001), and circumference of device skirt and the LVOT (CD: 3.9 ± 2.08 mm vs. no CD: - 4.6 ± 5.24 mm, p < 0.001) between the two groups. Receiver operating characteristic curve analysis showed that an area difference of 77.7 mm 2 and circumference difference of 0.91 mm at LVOT were associated with postoperative CD with specificities of 0.83, 0.78 and sensitivity of 1.0, 1.0, respectively. Preoperative measurement of the LVOT may be useful in evaluating the risk of postoperative CD in patients receiving rapid deployment valve., (© 2021. The Japanese Society for Artificial Organs.)

Objective: The purpose of this study was to evaluate the changes in mitral annular motion after surgery in patients with aortic stenosis., Methods: Patients receiving Edwards (Edwards) valves were included in the study. Echocardiographic findings were compared among the three treatments postoperatively, at discharge, and at 1 year after the surgery. Mitral annular motion was evaluated by e prime, using tissue doppler imaging., Results: There were 111 patients receiving Inspiris, 30 patients receiving Intuity and 241 patients receiving Sapien 3. The patients receiving Sapien 3 were significantly older, (Inspiris: 71 ± 6.7 years vs. Intuity: 75 ± 5.2 years vs. Sapien 3: 84 ± 5.1 years, p < .001), and prevalence of hemodialysis were significantly higher in patients receiving Intuity (Inspiris: 11.7% vs. Intuity: 46.7% vs. Sapien 3: 0.0%, p < .001). There was a significant improvement in mean pressure gradient in all groups (Inspiris: 55 ± 21.2-13 ± 5.2 mmHg, p < .001; Intuity: 48 ± 17.6-12 ± 4.9 mmHg, p < .001, Sapien 3: 55 ± 16.6-14 ± 5.2 mmHg, p < .001). Decalcification was associated with increase in e prime after surgery (no decalcification: 0.10 ± 1.280 cm/s vs. decalcification: 0.68 ± 1.405 cm/s, p < .001) Further, existence of stent was associated with less increase in e prime after surgery (no stent: 0.83 ± 1.210 cm/s vs. stent: 0.10 ± 1.356; p < .001). Multivariate analysis showed that existence of stent but not decalcification of the aortic valve was independently associated with changes in e prime after surgery (β: -.4679, 95% confidence interval: -0.93389 to -0.00200, p = .049)., Conclusions: Although improvement in pressure gradient was achieved in all treatments, existence of stent inhibited mitral annular motion after surgery., (© 2022 Wiley Periodicals LLC.)

Objectives: We aimed to determine whether non-A non-B aortic dissection (AD) differs in morphologic and haemodynamic properties from type B AD., Methods: We simulated and compared haemodynamics of patients with acute type B or acute non-A non-B AD by means of computational fluid dynamics. Wall pressure and wall shear stress (WSS) in both the true lumen (TL) and false lumen (FL) at early, mid- and late systole were evaluated. Morphology, WSS and the FL/TL wall pressure ratio were compared between groups., Results: Nineteen patients (type B, n = 7; non-A non-B, n = 12) were included. The median age (51 [46, 67] vs 53 [50, 63] years; P = 0.71) and a complicated course (14% vs 33%; P = 0.6) did not differ between the type B group and the non-A non-B group. However, the median entry tear width was increased in the non-A non-B group (9.7 [7.3, 12.7] vs 16.3 [11.9, 24.9] mm; P = 0.010). Streamlines showed, in patients with non-A non-B AD, blood from the TL flowed into the FL via the entry tear. Prevalence of a FL/TL wall pressure ratio >1.0 (type B versus non-A non-B) at early, mid- and late systole was 57% vs 83% (P = 0.31), 43% vs 83% (P = 0.13) and 57% vs 75% (P = 0.62), respectively. WSS did not differ between the groups., Conclusions: The increased FL/TL wall pressure ratio observed during systole in non-A non-B AD may beget a complicated presentation., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Interstitial lung disease (ILD) carries a risk for severe pneumonia in patients with rheumatoid arthritis (RA). Bronchiectasis, another risk of severe pneumonia, has not been well elucidated in RA. We investigated the types of respiratory diseases in RA and correlated them to severe pneumonia during the course of treatment using biologic DMARDs (bDMARDs), with special attention to bronchiectasis and ILD. RA patients were examined by computed tomography before starting bDMARDs and divided into three groups: normal, bronchiectasis and ILD. The log-rank test and Dunnett's multiple comparisons test were employed for the statistical analysis. Among 424 patients, 350 were categorized as normal, 32 as having bronchiectasis, and 42 as having ILD. Two in the normal group, three in the bronchiectasis group and four in the ILD group developed severe pneumonia. The log-rank test showed a significant difference among the three groups (p < 0.0001). The pneumonia-free rates in the bronchiectasis and ILD groups were significantly lower than the normal group, respectively, with Dunnett's multiple comparison test (p < 0.0001). This study suggests that the bronchiectasis that occurs in RA carries a risk of severe pneumonia during treatment with bDMARDs that is comparable to ILD., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: Early gastric cancers (EGCs) of the elevated type or with submucosal invasion are easily found by routine endoscopy. However, most early cancers are challenging to detect because of subtle morphological or color differences from surrounding atrophic mucosa and intestinal metaplasia. Linked color imaging (LCI) enhances mucosal color difference, making it easier to detect EGCs. The aim of this study is to clarify the advantages and possible disadvantages of LCI for screening for obscure EGC., Methods: A total of 665 malignant gastric lesions resected using endoscopic submucosal dissection between January 2015 and April 2018 were retrospectively reviewed. Obviously detectable lesions were not included in the main analysis when determining the target lesion. White light imaging (WLI)/LCI images of 508 endoscopically obscure malignant lesions were included in the final analysis and evaluated by three non-expert and three expert endoscopists using visibility scores for detection and extent., Results: The detection visibility scores using LCI were significantly higher than those using WLI regardless of lesion characteristics including location, size, histological type, depth of invasion, and Helicobacter pylori status. The detection score improved in 46.4% cases and deteriorated in 4.9% when the modality changed from WLI to LCI. A mixed-effects multivariate logistic regression analysis showed that use of LCI (odds ratio [OR] 2.57), elevated type (OR 1.92), invasion to submucosa (OR 2.18) were significantly associated with improved visibility of EGC., Conclusions: Linked color imaging significantly improves visibility of EGC regardless of differences in lesion morphology, histology, location, depth of invasion, and H. pylori status compared to conventional WLI., (© 2021 Japan Gastroenterological Endoscopy Society.)

Objectives: The incidence rate of distal stent graft-induced new entry (d-SINE) after frozen elephant trunk technique for aortic dissection remains controversial. The aim of this study was to investigate the incidence and seek the clinical and anatomical predictive factors., Methods: This study is a retrospective multicentre evaluation of complications including d-SINE, aortic events and reintervention after the frozen elephant trunk procedure for aortic dissection., Results: Our cohort included a total of 177 consecutive patients who underwent the frozen elephant trunk procedure for acute and chronic aortic dissection at 5 centres in Japan from May 2014 to March 2021. The incidence rate of d-SINE was 14.1% (25/177 patients). The cumulative incidence of d-SINE was 7.1%, 12.4% and 21.4% after 12, 36 and 60 months, respectively. d-SINE was not associated with mid-term survival rate. After competing risk regression analysis, onset time >48 h (subdistribution hazard ratio, 3.80; 95% confidence interval, 1.13-12.79; P = 0.031) was detected as an independent predictor., Conclusions: Awareness that there is a relatively higher incidence of d-SINE after frozen elephant trunk procedures is important. Non-hyper-acute phase was detected as an independent risk factor. Pre-emptive endovascular repair may be appropriate to protect new entry in high-risk patients., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Context: Few instruments in Japanese assess health-related quality of life in pediatric cancer patients., Objectives: To translate the Memorial Symptom Assessment Scale (MSAS) into Japanese pediatric and proxy versions (MSAS-J 7-12, MSAS-J 13-18, and MSAS-J-Proxy) and assess validity and reliability., Methods: Phase I comprised forward-backward translation and pilot testing in 13 children and 16 guardians. Phase II consisted of psychometric testing of the three MSAS-J versions in 162 children and 238 guardians. Internal consistency, test-retest reliability, and construct and known-group validity of the MSAS-J were assessed., Results: Cronbach's alpha coefficients for the total and subscale scores were over 0.70, excluding the psychological symptom (PSYCH) subscale score of the MSAS-J 7-12. Most MSAS-J scores significantly inversely correlated with two versions of the Pediatric Quality of Life Inventory. A strong child-guardian correlation was shown in the total and subscale scores (ICC range 0.66-0.83). Kappa estimates showed acceptable child-guardian symptom agreement. MSAS-J 7-12 and proxy differentiated patients according to clinical status., Conclusion: MSAS-J is a reliable and valid instrument to assess symptoms among Japanese children with cancer., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to investigate the changes in pulse wave velocity (PWV) after aortic arch repair and to evaluate possible perioperative factors associated with an increase in PWV., Methods: Eighty-nine patients with preoperative and postoperative PWV measurements who underwent surgical treatment for true aortic arch aneurysm were included in the study. The patients were treated by prosthetic graft replacement with or without the frozen elephant trunk technique or by hybrid surgery with a stent graft. Changes in PWV and perioperative factors were evaluated., Results: Fifty-one patients were treated by prosthetic graft replacement; 22 patients were treated with the frozen elephant trunk procedure; and 16 patients were treated by hybrid surgery. A significant increase in PWV was observed in patients undergoing surgical treatment for aortic arch aneurysm regardless of the types of operations performed (all treatments: before, 1797 ± 397.8 cm/s vs after, 2061 ± 600.4 cm/s, P < 0.001; graft replacement: before, 1769 ± 398.1 cm/s vs after, 1895 ± 459.0 cm/s, P = 0.004; frozen elephant trunk procedure: before, 1911 ± 461.9 cm/s vs after 2307 ± 826.9 cm/s, P = 0.005; hybrid surgery: before, 1732 ± 273.3 cm/s vs after, 2254 ± 484.6 cm/s, P < 0.001). Differences in PWV were largest in patients treated with hybrid surgery and lowest in those treated with graft replacement (P = 0.002). In univariate analysis, an increase in PWV was positively correlated with treatment length (r = 0.41; P < 0.001); the use of a postoperative beta blocker was associated with a smaller increase in postoperative PWV (with: 165.0 ± 371.92 cm/s vs without: 439.4 ± 530.38 cm/s, P = 0.005). Multivariate analysis suggested that treatment length (coefficient 3.31, 95% confidence interval 0.056-6.562, P = 0.046) and postoperative beta blocker (coefficient -220.08, 95% confidence interval -401.972 to -38.183, P = 0.018) were factors independently associated with changes in PWV., Conclusions: There was a significant increase in PWV after aortic arch repair. Treatment length and use of postoperative beta blockers were factors associated with changes in postoperative PWV. Minimizing the treatment length and using postoperative beta blockers may attenuate the effects of prostheses on postoperative PWV., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Purpose: We investigated factors contributing to coagulopathy in patients with acute type A aortic dissection (ATAAD) and coagulopathy's influence on patient outcomes., Methods: We grouped 420 patients who underwent ATAAD repair-none under anticoagulation therapy or with liver disease-by the prothrombin time-international normalized ratio (PT-INR) at admission:  <  1.2 (no coagulopathy, n  =  371), 1.2-1.49 (mild coagulopathy, n  =  33), or  ≥  1.5 (severe coagulopathy, n  =  16). We then compared the clinical presentation, dissection morphology, and outcomes among the groups. We assessed the PT-INR in relation to the preoperative hemodynamics and searched for factors predictive of a PT-INR  ≥  1.2., Results: The transfusion volume and operation time were increased among patients with coagulopathy (P  <  0.05). The in-hospital mortality (15.2-37.5% vs. 5.1%, P  < 0.001) and 5-year survival (61.1-74.4% vs. 87.6%) were relatively poor for these patients. The median PT-INR was 1.03 (0.97-1.1) for patients with stable hemodynamics (n  =  318), 1.11 (1.02-1.21) for those in shock (blood pressure  <  80 mmHg) not given cardiopulmonary resuscitation (CPR) (n  =  81), and 1.1 (1.0-1.54) for those in shock given CPR (n  =  21) (P  < 0.001). A multivariable analysis identified shock (P  <  0.001), a partially thrombosed false lumen (P  =  0.006), and mesenteric malperfusion (P  =  0.016) as predictive variables., Conclusions: Shock, a partially thrombosed false lumen, and mesenteric malperfusion appear to be predictive of dissection-related coagulopathy, which influences outcomes negatively., (© 2021. The Author(s), under exclusive licence to Springer Nature Singapore Pte Ltd.)

Purpose: In this pilot study, the authors compared the effects of antioxidant co-supplementation therapy and methylcobalamin therapy in patients with impaired semen quality., Methods: Eighty-four subjects who visited male infertility clinics and showed abnormal semen test results were randomly subjected to one of the two therapies: antioxidant co-supplementation therapy with vitamin C, vitamin E, coenzyme Q10, and flaxseed oil or methylcobalamin therapy. The oxidation-reduction potential (ORP) and 8-hydroxy-2'-deoxyguanosine levels were used as indicators of oxidative stress levels in semen. Semen analysis was also performed., Results: The authors obtained results from 67 patients who had completed 3 months of treatment. Neither antioxidant co-supplementation therapy nor methylcobalamin therapy changed the semen parameters significantly (except for the sperm concentration, which was increased by the latter therapy). When the pre-treatment ORP value in semen was higher than the cutoff value, both therapies significantly increased the sperm concentration. The 8-hydroxy-2'-deoxyguanosine level did not yield any meaningful predictive value with regard to increased sperm concentrations., Conclusions: Both antioxidant co-supplementation therapy and methylcobalamin therapy increased the sperm concentration in patients with impaired semen quality when the basal ORP levels in their semen were elevated., Competing Interests: Kazumitsu Yamasaki, Masahiro Uchida, Noriko Watanabe, Tatsuji Ihana, Yukari Ishiguro, Shinnosuke Kuroda, Teppei Takeshima, Yasushi Yumura, Makiko Mieno, Kaoru Yoshida, Teruaki Iwamoto, and Hiroyuki Nishiyama declare that they have no conflict of interest. The antioxidant co‐supplement (SO Support II) and methylcobalamin were provided by Partners. This company did not play any role in the design of the study, collection, analysis, interpretation of data, writing of the manuscript, or in the decision to publish the results., (© 2022 The Authors. Reproductive Medicine and Biology published by John Wiley & Sons Australia, Ltd on behalf of Japan Society for Reproductive Medicine.)

Objectives: Transcatheter aortic valve replacement is known to be associated with improved haemodynamics in patients with aortic stenosis and a small aortic annulus. However, limited benchmark data are available regarding the long-term outcomes in patients treated with surgical aortic valve replacement (SAVR). We investigated the long-term outcomes of SAVR using a 19-mm bioprosthesis., Methods: This study included consecutive patients who underwent SAVR using a 19-mm bioprosthesis at our hospital between 2008 and 2012., Results: In a total of 132 patients, moderate and severe prosthesis-patient mismatch occurred in 36 (27.3%) and 7 patients (5.3%), respectively. The median follow-up period was 7.7 years. The overall 5- and 10-year survival rates were 79.4% and 52.9%, respectively. The 5- and 10-year freedom from major adverse valve-related events rates were 89.6% and 74.2%, respectively. Neither moderate nor severe prosthesis-patient mismatch was associated with late mortality, major adverse valve-related events or heart failure. Follow-up echocardiographic data were obtained at a median interval of 4.8 years in 80% of patients who survived ≥6 months postoperatively. Follow-up echocardiographic data showed a significantly increased left ventricular ejection fraction, decreased mean transvalvular/transprosthetic pressure gradients and a decreased mean left ventricular mass. At follow-up, we observed moderate or severe haemodynamic structural valve deterioration in 17 patients; however, structural valve deterioration did not affect late survival or freedom from major adverse valve-related events rates, or heart failure., Conclusions: SAVR using the 19-mm bioprosthesis was associated with satisfactory long-term clinical and haemodynamic outcomes., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: In Japan, donations after circulatory death kidney transplantation are widely performed due to legislation delays. The number of donations after brain death kidney transplantations is increasing, but the target remains unmet. We reviewed the outcomes of donation after circulatory death in Japan., Methods: We analyzed 2923 deceased kidney transplantations (2239: donation after circulatory death (DCD), 684: donation after brain death (DBD)) performed in Japan from 2000 to 2019. The outcomes of the DCD and DBD groups were compared. We examined the risk factors for graft loss in the DCD group., Results: The 5-year patient survival and death-censored graft survival rates of the DCD group, obtained by propensity score matching, were 93.6% and 95.2%, respectively, which were equivalent to 94.2% and 93.8%, respectively, obtained in the DBD group. Older donors (≥ 50 years) and prolonged cold ischemia time (≥ 12 h) were risk factors for graft loss; in the presence of these, graft survival was lower in the DCD group., Conclusions: Older donors and prolonged cold ischemia time reduced graft survival in the DCD group. Proper evaluation of donors and careful preparation for transplant surgery are, therefore, essential to ensure good transplant outcomes., (© 2021. Japanese Society of Nephrology.)

Activation of signal transducer and activator of transcription (STAT)3 has been reported in many cancers. It is also well known that STAT3 is activated in skin lesions of psoriasis, a chronic skin disease. In this study, to ascertain whether patients with psoriasis have a predisposition to STAT3 activation, we examined phosphorylated STAT3 in cancer cells of psoriasis patients via immunohistochemistry. We selected patients with psoriasis who visited the Department of Dermatology, Jichi Medical University Hospital, from January 2000 to May 2015, and had a history of cancer. We performed immunostaining for phosphorylated STAT3 in tumor cells of five, four, and six cases of gastric, lung, and head and neck cancer, respectively. The results showed that there was no significant difference in STAT3 activation in any of the three cancer types between the psoriasis and control groups. Although this study presents limitations in its sample size and inconsistency in the histology and differentiation of the cancers, results suggest that psoriasis patients do not have a predisposition to STAT3 activation. Instead, STAT3 activation is intricately regulated by each disorder or cellular microenvironment in both cancer and psoriasis.

Objective We studied three types of estimated glomerular filtration rate (eGFR) equations and evaluated which type was strongly associated with comorbidities in living kidney transplantation (LKT) donors. Methods We compared the Japanese modified eGFR, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Collaboration equations (Jm-eGFR, Jm-MDRD, and Jm-CKD-EPI, respectively) for Japanese LKT donors with respect to their relationships with obesity, hypertension, diabetes, cardiovascular disease, and stroke. Results Of the 8,176 enrolled Japanese LKT donors, the eGFR calculated using Jm-CKD-EPI (eGFR/Jm-CKD-EPI) detected significant differences in 4 of 5 comorbidities between the comorbidity-positive and comorbidity-negative groups, whereas the eGFR calculated using Jm-MDRD (eGFR/Jm-MDRD) and Jm-eGFR (eGFR/Jm-eGFR) detected only 3 and 1 comorbidities, respectively. The area under the receiver operating characteristic curve of Jm-CKD-EPI was larger than those of Jm-eGFR and Jm-MDRD for all five comorbidities. Conclusion We found that the eGFR/Jm-CKD-EPI correlated better with comorbidities than the eGFR/Jm-eGFR and eGFR/Jm-MDRD in Japanese LKT donors. We recommend using the eGFR/Jm-CKD-EPI for the initial assessment of the renal function in LKT donor candidates when evaluating the presence of associated comorbidities.

Background: Diabetic kidney disease (DKD) is one of the main complications of type 2 diabetes mellitus (T2DM). DKD is a known risk factor for end-stage renal disease, cardiovascular disease, and all-cause death. Effective intervention for early-stage DKD is vital to slowing down the progression of kidney disease and improve prognoses. Mobile health (mHealth) is reportedly effective in supporting patients' self-care and improving glycemic control, but the impact of mHealth on DKD has yet to be shown., Objective: The purpose of this study is to evaluate the efficacy of standard therapy with the addition of a self-management support system, DialBetesPlus, in patients with DKD and microalbuminuria., Methods: This study is a prospective, randomized, open-label, multicenter clinical trial. The target population consists of 160 patients diagnosed with T2DM accompanied by microalbuminuria. We randomly assigned the patients to 2 groups-the intervention group using DialBetesPlus in addition to conventional therapy and the control group using conventional therapy alone. DialBetesPlus is a smartphone application that supports patients' self-management of T2DM. The study period was 12 months, with a follow-up survey at 18 months. The primary outcome was a change in albuminuria levels at 12 months. Secondary outcomes included changes in physical parameters, blood test results (glycemic control, renal function, and lipid metabolism), lifestyle habits, self-management scores, medication therapy, and quality of life., Results: The study was approved in April 2018. We began recruiting patients in July 2018 and completed recruiting in August 2019. The final 18-month follow-up was conducted in March 2021. We recruited 159 patients and randomly allocated 70 into the intervention group and 61 into the control group, with 28 exclusions due to withdrawal of consent, refusal to continue, or ineligibility. The first results are expected to be available in 2021., Conclusions: This is the first randomized controlled trial assessing the efficacy of mHealth on early-stage DKD. We expect that albuminuria levels will decrease significantly in the intervention group due to improved glycemic control with ameliorated self-care behaviors., Trial Registration: UMIN-CTR UMIN000033261; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr&#95;view.cgi?recptno=R000037924., International Registered Report Identifier (irrid): DERR1-10.2196/31061., (©Yuki Kawai, Akiko Sankoda, Kayo Waki, Kana Miyake, Aki Hayashi, Makiko Mieno, Hiromichi Wakui, Yuya Tsurutani, Jun Saito, Nobuhito Hirawa, Tadashi Yamakawa, Shiro Komiya, Akihiro Isogawa, Shinobu Satoh, Taichi Minami, Uru Osada, Tamio Iwamoto, Tatsuro Takano, Yasuo Terauchi, Kouichi Tamura, Toshimasa Yamauchi, Takashi Kadowaki, Masaomi Nangaku, Naoki Kashihara, Kazuhiko Ohe. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 17.08.2021.)

Objectives: To investigate the impact of switching from tenofovir disoproxil fumarate (TDF)- to tenofovir alafenamide (TAF)-containing regimens on bone, kidney, serum lipids and body weight among Asian patients., Methods: A prospective, multicentre, observational cohort study was conducted at three centres for HIV infection in Japan during 2017-2019. HIV-infected adults previously treated with TDF-containing regimens and scheduled to switch to TAF-containing regimens were included. Bone mineral density (BMD), renal markers, lipids and weight were measured consecutively from 12 months before to 12 months after the switch., Results: Among 118 patients evaluated, the mean percentage change to spine BMD during 1 year of TAF treatment was higher than that during 1 year of TDF treatment (mean difference = 1.9%; 95% confidence interval (CI): 0.8-3.1). Urine protein and β 2 -microglobulin levels decreased significantly after the switch, while low-density lipoprotein cholesterol and triglycerides increased. During the TDF and TAF periods, the mean weight gains were 0.2 and 1.9 kg, respectively (mean difference = 1.6 kg; 95% CI: 0.9-2.3). Subgroup analysis revealed a significant difference between the mean body weight change associated with an integrase inhibitor (INSTI) (+2.8 kg) and that associated with a non-INSTI (+1.2 kg) third agent treatment only during the TAF period., Conclusions: Among predominantly Japanese HIV-infected patients, BMD and renal tubular markers improved, while lipid profiles worsened significantly after the switch. Weight gain during the TAF period was larger than that during the TDF period. Concurrent use of INSTI with TAF may act synergistically to gain body weight., (© 2021 The Authors. HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association.)

Background: Neoadjuvant systemic therapy (NST) induces tumor shrinkage and boosts the chance of breast-conserving thearpy (BCT) in patients with breast cancer. However, only a few trials have evaluated the effect of NST in conversion from BCT ineligibility to BCT eligibility in HER2-positive breast cancer., Methods: We conducted the surgical sub-study of a phase II randomized trial, which compared standard neoadjuvant treatment or an experimental treatment modified according to the interim Ki-67 evaluation in women with stage II or III HER2-positive breast cancer. The treating surgeons assessed eligibility for BCT before and after NST. We evaluated the change in BCT eligibility following NST. We also analyzed the type of surgery performed and the success rate of BCT., Results: Two hundred six patients were included in this study. Of these, 44.0% were considered BCT candidates at baseline, while 69.8% were deemed eligible for BCT after NST (P < 0.001). Among non-BCT candidates at baseline, 46% successfully converted to BCT candidates. Of 139 patients deemed eligible for BCT following NST, 84.2% attempted BCT, and successful BCT, defined as tumor-free at all surgical margins, was achieved in 96.8% of patients. Different treatment arms did not affect the rate of post-NST BCT eligibility (70.0% vs 69.7%)., Conclusions: This study demonstrated that NST resulted in an absolute increase of 25.8% in the rate of BCT eligibility in HER2-positive breast cancer. About a half of non-BCT candidates converted to BCT candidates. BCT was successful in most patients who attempted BCT. There were still patients who chose mastectomy even though they were deemed eligible for BCT. Patients considered BCT-ineligible due to large tumor size most likely converted to BCT-eligible with NST. On the other hand, NST had less impact on the surgical indication of patients with multicentric disease or probable poor cosmetic outcome., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: We investigated the long-term clinical and hemodynamic outcomes after aortic valve replacement (AVR) with a 17-mm mechanical valve.Methods and Results:Between January 2005 and December 2011, 80 patients with aortic stenosis underwent AVR with the 17-mm St. Jude Medical Regent prosthetic valve. Echocardiography was performed preoperatively, at discharge, and at follow-up, which was performed at least 2 years postoperatively (median interval, 7.3 years). Prosthesis-patient mismatch (PPM) was defined as an indexed effective orifice area <0.85 cm 2 /m 2 at discharge and occurred in 25 patients (31%). The median follow-up period was 8.7 years (100% complete). Overall in-hospital mortality was 2.5% (2 patients) with 27 late deaths (34%). The 5- and 10-year survival rates were 78.7% and 63.0%, respectively. Peripheral arterial disease and concomitant mitral valve repair were independent predictors of late mortality. The 5- and 10-year freedom from major adverse valve-related events (MAVRE) rates were 91.6% and 83.5%, respectively. PPM at discharge did not affect long-term survival, freedom from MAVRE, or freedom from heart failure. Echocardiographic data at follow-up revealed a significant reduction in the mean left ventricular mass index (LVMI). LVMI reduction observed at follow-up was similar between patients with and without PPM., Conclusions: AVR with the 17-mm mechanical prosthesis had acceptable long-term clinical and hemodynamic outcomes. Significant reduction in LVMI was observed regardless of PPM.

Background: The prevalence of obesity among Japanese acute type A aortic dissection (ATAAD) patients and its effect on repair outcomes remain to be elucidated. Methods and Results: The prevalence of obesity (body mass index [BMI] ≥30.0 kg/m 2 ) among 1,059 patients (mean [±SD] age 64.3±12.7 years) who underwent ATAAD repair between 1990 and 2018 was compared with that among the general Japanese population (National Health and Nutrition Survey data). The prevalence of obesity among male patients (17.1% [6/35], 20.0% [18/90], and 14.4% [20/139] for those aged 20-39, 40-49, and 50-59 years, respectively) was significantly higher than that among the age- and sex-matched general population. The 1,059 patients were divided into groups according to weight (normal [BMI <25.0 kg/m 2 ; n=742], overweight [BMI 25.0-29.9 kg/m 2 ; n=248], or obese [BMI ≥30.0 kg/m 2 ; n=69]). Comparing the normal weight, overweight, and obese groups revealed significant differences among the 3 groups in median cardiopulmonary bypass time (143, 167, and 183 min, respectively), ventilation >48 h (44.5%, 60.1%, and 78.3%, respectively), and in-hospital mortality (7.0%, 7.3%, and 17.4%, respectively), but not in 30-day survival. Shock, visceral malperfusion, operation time >360 min, obesity, and coronary malperfusion were identified as predictors of in-hospital mortality. Conclusions: The prevalence of obesity is increased among Japanese male patients with ATAAD aged ≤59 years. Obesity may increase these patients' operative risk; overweight does not., Competing Interests: None., (Copyright © 2020, THE JAPANESE CIRCULATION SOCIETY.)

Background: Cervical lymphadenopathy is commonly seen in general practice, and its etiology is diverse. Establishing the diagnostic strategy for lymphadenopathy would be desirable to avoid overlooking neoplasms or other critical conditions. This study aims to identify the useful laboratory parameters for cervical lymphadenopathy that require clinical observation or intervention., Methods: The participants were outpatients presenting cervical swelling or cervical lymph node (LN) pain who consulted the General Internal Medicine department from 2010 to 2016. We evaluated the characteristics, physical findings, and laboratory parameters with final diagnoses by multivariate logistic regression analysis. We categorized the final diagnoses as "Clinical Intervention Required Group (CIRG)" including necrotizing lymphadenitis, hematologic neoplasms, metastatic lymphadenopathy, tuberculous lymphadenitis, bacterial infectious diseases, infectious mononucleosis, autoimmune diseases, and other abnormal conditions or "No-CIRG" not requiring further clinical observation or intervention., Results: We evaluated 409 participants, with 130 (31.8%) diagnosed as belonging to the CIRG. There was an association between CIRG and various parameters: age ≥60 years old (adjusted odds ratio [AOR], 2.70; 95% confidence interval [CI], 1.48-4.90), having a referral (AOR, 1.83; 95% CI, 1.12-3.00), diameter of LN ≥ 2 cm (AOR, 1.91; 95% CI, 1.05-3.48), fixed LNs (AOR, 2.74; 95% CI, 1.02-7.37), and lactate dehydrogenase (LD) ≥400 U/L (AOR, 3.78; 95% CI, 1.46-9.77). Eighty-two percent of LD ≥ 400 cases in the CIRG were infectious mononucleosis or necrotizing lymphadenitis., Conclusions: Besides the clinical indicators reported previously, we may apply an elevated LD level as a useful indicator of cervical lymphadenopathy that requires further clinical observation or intervention., Competing Interests: The authors have stated explicitly that there are no conflicts of interest in connection with this article., (© 2020 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

Purpose: We investigated the etiology and impact on outcomes of polycystic kidney disease in patients with abdominal aortic aneurysm., Methods: Eight-hundred patients who underwent open (n = 603) or endovascular aortic repair (n = 197) were divided into three groups: no cyst (n = 204), non-polycystic kidney (n = 503), and polycystic kidney (≥ 5 cysts in the bilateral kidneys, n = 93). The characteristics and outcomes were compared among the groups., Results: In the polycystic kidney group, the age was increased and the proportions of patients with male sex, hypertension, and estimated glomerular filtration rate < 30 mL/min/1.73 m 2 were greater. The overall hospital mortality rates were similar. The incidence of acute kidney injury after elective open aortic repair was increased in the polycystic kidney group (12%, 17%, and 29%, P = 0.020). In the polycystic kidney group, 80 patients did not have renal enlargement or a family history of renal disease, while 13 (corresponding to 1.6% [13/800] of the overall patients), had renal enlargement, suggesting the possibility of hereditary polycystic kidney disease., Conclusions: In our cohort, 1.6% of the patients with abdominal aortic aneurysm who underwent surgery were at risk of hereditary polycystic kidney disease. Polycystic kidney disease was associated with acute kidney injury after open aortic repair.

Semen quality is affected by environmental factors, endocrine function abnormalities, and genetic factors. A GWAS recently identified ERBB4 at 2q34 as a genetic locus associated with sperm motility. However, GWASs for human semen volume and sperm concentration have not been conducted. In addition, testis size also reportedly correlates with semen quality, and it is important to identify genes that affect testis size. Reproductive hormones also play an important role in spermatogenesis. To date, genetic loci associated with plasma testosterone, sex hormone-binding globulin (SHBG), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) levels have been identified using GWASs. However, GWASs have not identified any relevant loci for plasma inhibin B levels. We conducted a two-stage GWAS using 811 Japanese men in a discovery stage followed by a replication stage using an additional 721 Japanese men. The results of the discovery and replication stages were combined into a meta-analysis. After setting a suggestive significance threshold for P values < 5 × 10 -6 　in the discovery stage, we identified ten regions with SNPs (semen volume: one, sperm concentration: three, testes size: two, and inhibin B: four). We selected only the most significant SNP in each region for replication genotyping. Combined discovery and replication results in the meta-analysis showed that the locus 12q21.31 associated with plasma inhibin B levels (rs11116724) had the most significant association (P = 5.7 × 10 -8 ). The LRRIQ1 and TSPAN19 genes are located in the 12q21.31 region. This study provides new susceptibility variants that contribute to plasma inhibin B levels.

Objectives: We investigated the association between sarcopenia (a marker of frailty) and outcomes after coronary artery bypass grafting (CABG)., Methods: This study included 304 patients who underwent elective isolated off-pump CABG at our hospital between October 2008 and August 2013. Psoas muscle area was measured on preoperative computed tomography scans. Sarcopenia was defined as the lowest sex-specific quartile of the psoas muscle area index (the psoas muscle area normalized for height). Patients were categorized into a sarcopenia group (76 patients) and a non-sarcopenia group (228 patients). Patients in the sarcopenia group were older and showed a lower body mass index, lower serum haemoglobin and albumin levels and lower prevalence of dyslipidaemia but higher prevalence of renal dysfunction and peripheral artery disease. The mean follow-up period was 4.5 ± 2.3 years., Results: The cut-off values for sarcopenia were psoas muscle area index 215 and 142 mm2/m2 in men and women, respectively. No intergroup difference was observed in the in-hospital mortality and morbidity rates. After risk adjustment using inverse probability weighting analysis, late mortality rates were significantly higher in the sarcopenia group than in the non-sarcopenia group (P = 0.022). Multivariable analysis showed that preoperative sarcopenia was an independent predictor of late mortality (hazard ratio 4.25, 95% confidence interval 2.18-8.28; P < 0.001). Preoperative sarcopenia was not associated with major adverse cardiac and cerebrovascular events during follow-up., Conclusions: Preoperative sarcopenia (assessed by psoas muscle area index) was associated with late mortality after CABG and effectively predicts postoperative prognosis., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Outcomes of planned and unplanned (rescue) double arterial cannulation (DAC) in surgery for acute type A aortic dissection were investigated retrospectively., Methods: The study involved 805 patients who were divided into 4 groups according to the cannulation strategy: single cannulation of the femoral artery (n = 338), axillary artery (n = 256), left ventricular apex (n = 52) or ascending aorta (n = 5) (total, n = 57), and DAC (n = 154). Patients who underwent DAC were divided between planned (n = 132) and rescue (n = 22) usage. Characteristics and outcomes were compared between groups. Both unmatched and propensity score-matched analyses were performed., Results: Shock (39%, 19%, 33% and 14%, in the femoral artery, axillary artery, left ventricular apex/ascending aorta and DAC, respectively) and leg malperfusion (5%, 16%, 16% and 26%, respectively) differed significantly (P < 0.001), but in-hospital mortality did not (9%, 8%, 18% and 7%, respectively; P = 0.096). The 5-year survival rates were 79.4%, 79.7%, 78.6% and 82.2%, respectively. Propensity score-matched analysis showed no statistically significant differences in in-hospital mortality rates (10%, 12%, 14% and 9%, respectively; P = 0.78) and 5-year survival rates (78.4%, 72.3%, 82.3% and 78.0%, respectively). The leading vessel combination and indications for planned and rescue DAC were the femoral and axillary arteries (98%) and true lumen narrowing and/or leg malperfusion (34%), and the axillary followed by femoral (77%) artery and low cardiopulmonary bypass flow (36%). In-hospital mortality in the planned and rescue DAC groups was 7% and 9%, respectively., Conclusions: DAC seems effective for both prevention and management of intraoperative malperfusion., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: To increase the influenza vaccination rate in Chiburijima Island, we diversified vaccination places from a single clinic to the seven town halls from all the districts., Methods: We retrospectively analyzed influenza vaccination coverage, vaccinees' district of residence, and location of vaccination place, from prevaccination screening questionnaires between October 2007 and March 2018. Except for home-visiting vaccination services, before 2011, influenza vaccination was provided only at a single clinic; after 2012, it was provided at the seven town halls in addition to the clinic. We calculated the vaccination rates among residents of Chiburijima Island, stratified by age groups and districts of residence., Results: Estimated influenza vaccination rates for all ages increased from 38% in 2007 to 58% in 2017. There was a 14% increase in coverage in 2010 (the year following the 2009 H1N1 pandemic) and a slight increasing trend after 2012. The vaccination coverage of residents, particularly of people ≥65 years old and living >1 km from the former vaccination place, increased after diversification of the vaccination place., Conclusions: Influenza vaccination rate in Chiburijima Island increased by 20% between 2007 and 2017, although the rate among the elderly Japanese people decreased by 4% based on the national data of routine immunization. Shortening the distance to vaccination places might improve the coverage as elderly people are often restricted due to transportation means. Sustained and multifaceted strategies are necessary for better immunization coverage., Competing Interests: The authors have stated explicitly that there are no conflicts of interest in connection with this article., (© 2020 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

Background: CYP2A6 is an enzyme involved in oxidation of a number of environmental chemicals, including nicotine, pro-carcinogenic nitrosamines and polycyclic aromatic hydrocarbons (PAHs). The whole gene deletion of CYP2A6 (CYP2A6*4) is prevalent in East Asian population. Whether or not CYP2A6*4 associates with cancer is still controversial., Methods: We undertook an association study to determine whether deletion of CYP2A6 gene associates with total cancer and major cancer types employing data of consecutive autopsy cases registered in the Japanese single-nucleotide polymorphisms for geriatric research (JG-SNP) database. The presence of cancer were inspected at the time of autopsy and pathologically confirmed. Genotyping for CYP2A6 wild type (W) and deletion (D) was done by allele specific RT-PCR method., Results: Among 1373 subjects, 826 subjects (60.2%) were cancer positive and 547 subjects (39.8%) were cancer negative. The genotype frequency in the whole study group for WW, WD and DD were 65.0, 30.6 and 4.4%, respectively, which obeyed the Hardy-Weinberg equilibrium (p = 0.20). Total cancer presence, as well as major cancers including gastric, lung, colorectal, and blood cancers did not show any positive association with CYP2A6 deletion. When male and female were separately analyzed, CYP2A6 deletion associated with decreased gastric cancer risk in female (OR = 0.49, 95%CI: 0.25-0.95, p = 0.021, after adjustment for age, smoking and drinking). When smoker and non-smoker were separately analyzed, CYP2A6 deletion associated with decreased total cancer in female nonsmokers (OR = 0.67, 95%CI: 0.45-0.99, p = 0.041 after adjustment). On the other hand, CYP2A6 deletion associated increase blood cancers in smokers (OR = 2.05, 95%CI: 1.19-3.53, p = 0.01 after adjustment)., Conclusion: The CYP2A6 deletion may not grossly affect total cancer. It may associate with individual cancers in sex and smoking dependent manner. Further studies with larger sample size are warranted to confirm our results.

The HOTAIR gene encodes a long noncoding RNA (lncRNA), which functions in development and tumorigenesis. A single nucleotide polymorphism (SNP) rs920778 in the HOTAIR gene, has been recurrently studied for susceptibility to many cancers including oesophageal cancer, gastric cancer, lung cancer, and hepatocellular carcinoma. Most of these studies were conducted in Chinese populations, and a few in Turkish, Iranian, and Portuguese populations. They mostly give rise to controversial results. It still remains largely unknown whether the cancer risk is conferred in a Japanese population. Here, we established an association study on the representative SNP rs920778, to examine its contribution to the presence of cancer in consecutive autopsy cases in the JG-SNP database. A total of 1373 subjects (mean age 80) including 827 cancer positive and 546 cancer negative subjects were analyzed. As a result, the occurrence of overall cancer was not associated with the rs920778 polymorphism (p > 0.05). For each cancer type, we did not find association except for lung cancer (p = 0.04) which was more likely a by-chance association after multiple testing. Our findings imply that rs920778 polymorphism does not affect total cancer presence and the effect on specific cancer types is also weak in the Japanese population., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Aortic dissection may induce a systemic inflammatory reaction. The etiological backgrounds for elevation of the white blood cell count remain to be clarified. In 466 patients with acute type A aortic dissection treated surgically within 48 hours of symptom onset, the etiologic background of an elevated admission white blood cell count and the effect of such elevation on outcomes were assessed retrospectively. Patients' white blood cell count differed significantly in relation to the extent of dissection, with a median (25th, 75th percentile) white blood cell count of 10.4 (8.1, 13.9) x 103/μL for dissection confined to the ascending aorta, 10.5 (8.2,13.) 103/μL for dissection extending to the aortic arch/descending aorta, 11.1 (8.2, 13.7) x 103/μL for extension to the abdominal aorta, and 13.3 (9.8, 15.9) x 103/μL for extension to the iliac artery (p<0.001). With 11.0 x 103/μL used as the cut-off value for white blood cell count elevation, multivariable analysis showed current smoking (p<0.001; odds ratio, 2.79), dissection extending to the iliac artery (p = 0.006; odds ratio, 1.79), age (p = 0.007, odds ratio, 0.98), and no coronary ischemia (p = 0.027, odds ratio, 2.22) to be factors related to the elevated white blood cell count. Mean age differed significantly between patients with and without an elevated white blood cell count (62.3 vs. 68.3 years, p <0.001). Although in-hospital mortality was similar (7.5% vs.10.9%, p = 0.19), 5-year survival was lower in patients without an elevated count (85.7% vs. 78.6%, p = 0.019), reflecting their more advanced age. In conclusion, our data suggest that dissection morphology and patient age influence the acute phase systemic inflammatory response associated with an elevated white blood cell count in patients with ATAAD. A better understanding of this relation may help optimize diagnosis and perioperative care., Competing Interests: The authors have declared that no competing interests exist.

This is a Japanese retrospective single-center study carried out between 1 January 2010 and 21 November 2018 at the Department of Dermatology in Jichi Medical University Hospital. The drug survival rate for six biologic agents used for the treatment of psoriasis was investigated. We reviewed the clinical records of 315 treatment series of 205 patients with moderate to severe psoriasis treated with adalimumab (103 cases), infliximab (70 cases), ustekinumab (66 cases), secukinumab (38 cases), brodalumab (12 cases) and ixekizumab (26 cases). In our study, ustekinumab revealed a trend towards higher drug survival among the six biologic agents. Ustekinumab had a higher drug survival rate than infliximab and secukinumab with significant differences by log-rank test among all patients and among biologic-naive (bio-naive) patients. There was no significant difference in drug survival between bio-naive and biologic-experienced (non-naive) patients in the treatment courses with adalimumab, infliximab, ustekinumab, secukinumab and ixekizumab. The dose augmentation therapy in infliximab-treated patients was associated with longer drug survival. Of all patients, 25 cases with generalized pustular psoriasis (GPP) were included, who functioned as the negative predictor for drug persistence with a hazard ratio of 1.87 (95% confidence interval, 1.12-3.11; P = 0.016). Our results reveal that ustekinumab had a superior drug survival, which is supported by the previous studies. Further studies are needed to clarify the efficacy of biologic agents on patients with GPP., (© 2019 Japanese Dermatological Association.)