Tenri Hospital

Background and aims: Gangrenous appendicitis, a type of complicated appendicitis, is an indication of emergency surgery due to a high risk of perforation. However, it can be challenging to diagnose preoperatively. This study aimed to validate the predictive factors of patients with gangrenous appendicitis and develop a novel scoring model based on objective parameters. Methods: This retrospective single-center study included 171 of 302 consecutive patients undergoing appendectomy between April 2014 and December 2023. Patients with perforation, chronic appendicitis, and appendicitis presenting with an abscess were excluded from the analysis. In other words, the study targeted Grades 1 and 2 on the American Association for the Surgery of Trauma (AAST) severity assessment scale. Computed tomography (CT) scan value was defined as the average value of fluid in the appendix lumen on plain CT scan. Univariate and multivariate analyses were performed to identify the independent objective predictors of gangrenous appendicitis. A new scoring model was developed based on the logistic regression coefficients of the independent predictors. The scores were then classified into three categories, and the probability of gangrenous appendicitis for each category was evaluated. Results: Overall, 46 (27%) and 125 (73%) patients presented with gangrenous appendicitis (=AAST Grade 2) and non-gangrenous (uncomplicated) appendicitis (=AAST Grade 1), respectively. The independent predictive factors of gangrenous appendicitis included a CT value of ≥24 HU, an appendiceal diameter of ≥12 mm, the presence of cecal mucosal edema, and a C-reactive protein level of ≥5.4 mg/dL. The scoring model, based on these four independent predictors, ranged from 0 to 4. The probability values of gangrenous appendicitis were 0%, 15%, and 97% in the low (0)-, moderate (1, 2)-, and high (3, 4)-risk categories, respectively. Conclusion: Our scoring model may assist in decision-making concerning emergency surgery and appendicitis management.

Abstract Background Guidelines on airway management in neonates and infants recommend using a stylet when a videolaryngoscope is used, but it is not clear if the use of a stylet facilitates tracheal intubation and which shape of the stylet is suitable in neonates. Methods As a preliminary simulation study of a randomized controlled cross-over design, 25 anesthesiologists (3 specialists, 11 senior residents, and 11 junior residents) used a McGrath® MAC videolaryngoscope (Covidien, Medtronic, Tokyo, Japan) blade 1 for tracheal intubation (of a 3.5-mm ID Shiley™ tube with a cuff), with one of four differently shaped stylets (C-shaped, J-shaped, hockey stick-shaped and double C-shaped) or without a stylet in a manikin of a neonate, and compared intubation times. Results Compared with intubation time without the use of a stylet, intubation time was significantly longer with the use of the J-shaped stylet (P = 0.007; median (95% CI) difference: 2 (1 to 2) s) or with the hockey stick-shaped stylet (P = 0.0002; median (95% CI) difference: 9 (9 to 10) s). In contrast, intubation time was similar between no stylet and the C-shaped stylet (P = 0.90; median (95% CI) difference: 0 (0 to 0) s) or between no stylet and the double C-shaped style (P = 0.60; median (95% CI) difference: 0 (0 to 0) s). Conclusions In conclusion, while time to tracheal intubation would be similar with and without the use of a stylet, the shape of the stylet would affect intubation time in neonates.

To compare the amplitudes and implicit times of the oscillatory (OPs) of the full-field electroretinograms (ERGs) to those of the 30 Hz flicker ERGs in differentiating eyes with diabetic retinopathy (DR) from normal eyes. Single-center observational study. Full-field ERGs were recorded in 55 patients with Type 2 diabetes mellitus (DM) and 20 normal control subjects. The amplitudes and implicit times of the OPs and of the 30 Hz flicker ERGs were measured. Optical coherence tomography angiography (OCTA) was used to record 3×3 mm enface images of the retina from which the vascular density (VD) of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) were obtained. The receiver operating characteristic (ROC) curves were used to determine the ability of each ERG parameter to discriminate diseased eyes from normal eyes. The significance of the correlations between each ERG parameter and the VD of the SCP and DCP was determined. The area under the ROC curves (AUCs) was significantly larger for the implicit times than for the amplitudes of each ERG component (P<0.005). There were no significant differences in the AUCs between the OPs and 30 Hz flicker ERGs in differentiating eyes with DM or DR from normal eyes. The implicit time of the 30 Hz flicker ERG had the highest significant correlation coefficient with the VD of the DCP (r = − 0.31, P <0.001). The OPs and 30 Hz flicker ERGs have equal ability in differentiating eyes with DR from normal eyes but with better ability for the implicit times than the amplitudes. The implicit time of the 30 Hz flicker ERG is the most sensitive parameter that is correlated with the reduction of VD among the full-field ERG components.

Abstract Aims There were no previous studies comparing aspirin vs. P2Y12 inhibitor monotherapy following short dual antiplatelet therapy (DAPT) after complex percutaneous coronary intervention (PCI). Methods and results We conducted a pre-specified subgroup analysis based on complex PCI in the 1-year results of the STOPDAPT-3 (ShorT and OPtimal Duration of Dual AntiPlatelet Therapy-3) trial, which randomly compared 1-month DAPT followed by aspirin monotherapy (aspirin group) with 1-month prasugrel monotherapy followed by clopidogrel monotherapy (clopidogrel group). The main analysis in the present study was the 30-day landmark analysis. The co-primary endpoints were cardiovascular events (a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or stroke) and major bleeding (Bleeding Academic Research Consortium 3 or 5). In the 30-day landmark analysis (N = 5833), there were 1415 patients (24.3%) who underwent complex PCI. There was a significant interaction between complex PCI and the effect of the aspirin group relative to the clopidogrel group for cardiovascular events (complex PCI: 3.3% vs. 5.2%, non-complex PCI: 4.3% vs. 3.6%, interaction P = 0.04) and net adverse clinical events (complex PCI: 4.8% vs. 7.2%, non-complex PCI: 5.3% vs. 4.4%, interaction P = 0.02), but not for bleeding events (complex PCI: 2.1% vs. 2.7%, non-complex PCI: 1.7% vs. 1.4%, interaction P = 0.35). Conclusions There was a significant interaction between complex PCI and the effect of aspirin monotherapy relative to clopidogrel monotherapy beyond 1 month and up to 1 year for cardiovascular events due to numerically lower risk of aspirin monotherapy in patients with complex PCI, while the effect of aspirin monotherapy relative to clopidogrel monotherapy was not different for bleeding regardless of complex PCI. Clinical trial registration ShorT and OPtimal duration of Dual AntiPlatelet Therapy after everolimus-eluting cobalt-chromium stent-3 [STOPDAPT-3]; NCT04609111.

Preoperative C-reactive protein (CRP) is a valuable prognostic biomarker in nonmetastatic clear cell renal cell carcinoma (nmccRCC). Incorporation of CRP into prognostic models may improve the prediction of oncologic outcomes. Herein, we aimed to develop and validate prognostic nomograms and an integrated software incorporating preoperative CRP level in nmccRCC. An international multi-institutional database was retrospectively analyzed for nmccRCC patients undergoing surgery. A total of 2284 patients were enrolled and randomly allocated to training (n = 1599, 70%) and validation (n= 685, 30%) cohorts. Nomograms predicting overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were developed in the training cohort using multivariable Cox regression, including preoperative CRP levels and other clinical factors. An integrated software was also created. The validation cohort was used to assess the performance of these nomograms. Following a median follow-up of 5.9 years, 318 (13.92%) patients died of any cause, 109 (4.77%) died of renal cancer, and 282 (12.35%) developed recurrence. The median (interquartile range) preoperative CRP level was 1.90 (0.80–5.68) mg/L. A high CRP level was independently associated with worse OS, CSS, and RFS. The nomograms and integrated software incorporating CRP significantly improved prediction accuracy compared with CRP alone. The C-indices for nomograms were 0.74 (95%CI, 0.69–0.80) for OS, 0.87 (0.82–0.93) for CSS, and 0.77 (0.71–0.82) for RFS in the validation cohort. Acceptable calibration was demonstrated at 12/36/60 months for OS, CSS, and RFS. The prognostic nomograms and the user-friendly integrated software incorporating preoperative CRP level may facilitate individualized risk stratification and treatment planning for patients with nmccRCC.

BackgroundC‐reactive protein (CRP) is a prognostic biomarker for clear cell renal cell carcinoma (ccRCC). However, there may be potential racial heterogeneity in distribution and prognostic impact of CRP level. We investigated potential racial differences in distribution and prognostic impact of preoperative CRP among Asian (AS), African American (AA), and Caucasian (CAUC) patients with non‐metastatic ccRCC (nmccRCC).MethodsWe retrospectively analyzed 1991 nmccRCC cases (AS/AA/CAUC: n = 968/223/800) undergoing nephrectomy from the international multi‐institutional database. We investigated CRP distributions and optimal cut‐off values for predicting recurrence‐free survival (RFS) and overall survival (OS) using Cox regressions for each racial group. Subgroup analyses considered comorbidities, pathological T stage, and Fuhrman grade.ResultsPreoperative CRP distributions differed significantly among the races, with median values of 0.90 mg/L (interquartile range, 0.40–2.33) for AS, 5.00 mg/L (1.98–12.20) for AA, and 3.55 mg/L (1.41–8.48) for CAUC (p < 0.01). Optimal cut‐off values for RFS were 1.2 mg/L in AS, 2.8 mg/L in AA, and 1.7 mg/L in CAUC, showing C‐indices of 0.77, 0.71, and 0.77, respectively. For OS, they were 1.6 mg/L in AS, 8.3 mg/L in AA, and 9.3 mg/L in CAUC, yielding C‐indices of 0.77, 0.70, and 0.74, respectively. Subgroup analyses revealed varying reference ranges of CRP levels among races (1.1–2.2/2.7–5.0/1.5–3.4 mg/L for RFS, and AS/AA/CAUC: 0.9–3.0/8.0–12.7/8.0–10.4 mg/L for OS, respectively).ConclusionThe preoperative CRP distributions and their optimal cut‐off values for predicting patient prognosis differed significantly among the races. Using race‐specific cut‐off values, CRP demonstrated consistently high‐prognostic accuracies, which may improve tailored patient management in nmccRCC.

This study aimed to investigate the differences in clinical outcomes between anatomical alignment and mechanical alignment in each knee, respectively, in patients who underwent bilateral total knee arthroplasty.

A recent meta-analysis has found that patients who have achieved remission of major depressive disorder (MDD) show cognitive dysfunction. Moreover, anticholinergic activity levels are associated with cognitive dysfunction, although the extent of these effects is unclear. Therefore, we measured serum anticholinergic activity (SAA) in blood samples of patients with remitted MDD and examined its relationship with cognitive function.