Expansion of 1 mL of Solution by Ultrasound-Guided Injection Between the Trapezius and Rhomboid Muscles: A Cadaver Study.

OBJECTIVE: An ultrasound-guided interfascial injection, which targets the space between the epimysia, is often performed for myofascial neck and shoulder pain. However, the relationship between the injection volume and clinical effectiveness has been controversial. We conducted an anatomical study with cadavers to measure the distribution of a small amount of pigment solution injected into the interfascial space. DESIGN: An experimental cadaveric study. SETTING: An institutional clinical anatomy laboratory. METHODS: We performed 20 ultrasound-guided injections with pigment solutions of 1.0 mL each into the space between the trapezius muscle and rhomboid muscle bilaterally on 10 cadaver specimens. Cadavers were then dissected and macroscopically evaluated for pigment distribution on the fascia of the muscular surfaces. The pigment distribution area of each injection site was visually confirmed and calculated using automatic area calculation software. RESULTS: Pigment solution exclusively within the interfascial space was visually confirmed in 95% (19/20) of injection sites. The median pigmented surface area (interquartile range) was 24.50 (16.17-30.76) cm2 on the deep side of the trapezius muscle and 18.82 (13.04-24.79) cm2 on the superficial side of rhomboid muscle; these measurements were statistically significantly different (P = 0.033). CONCLUSIONS: A pigment solution comprising as little as 1.0 mL injected under ultrasound guidance separated two adjacent muscles and spread to the wide area within the interfascial space. The difference in the pigment distribution area between the two adjacent muscles can be explained by the path made by the injection needle and several layers of fascia between the epimysium.

Initial assessment of femoral proximal fracture and acute hip arthritis using pocket-sized ultrasound: a prospective observational study in a primary care setting in Japan.

BACKGROUND: Acute hip pain caused by femoral proximal fractures or acute hip arthritis requires imaging for accurate diagnosis. Although pocket-sized ultrasound (PsUS) offers several advantages over other imaging modalities, there is limited information regarding its use in diagnosing femoral proximal fractures or acute hip arthritis. Thus, we aimed to validate the diagnostic accuracy of PsUS for both disorders. METHODS: In this prospective observational study, outpatients with acute hip pain were diagnosed according to a fixed procedure of the PsUS probe handling. We verified the diagnostic accuracy of PsUS findings (cortical discontinuity and joint fluid retention) and compared it with that of radiography, computed tomography, and magnetic resonance imaging. RESULTS: Our study included 52 outpatients (mean age, 78.0 years; female, 88.5%). Of 26 patients diagnosed with femoral proximal fractures, 14 had femoral neck fractures and 12 had femoral trochanteric fractures. The sensitivity and specificity for identifying cortical discontinuity in femoral proximal fractures were 0.96 and 0.92, respectively. The sensitivity for identifying either cortical discontinuity or joint fluid retention in femoral proximal fractures or acute hip arthritis was 0.97. CONCLUSIONS: Negative PsUS findings of cortical discontinuity and joint fluid retention in the hip are useful for ruling out femoral proximal fractures and acute hip arthritis. PsUS and radiography have comparable diagnostic accuracies, and PsUS could aid in the initial assessment of acute hip pain among the elderly in primary care settings.

Clinical relevance and low tumor-initiating properties of oligometastatic breast cancer in pulmonary metastasectomy.

Metastatic breast cancer is a systemic disease. However, certain subsets of patients, such as those with oligometastatic breast cancer (OMBC), have long-term survival prospects. Our aim was to evaluate the clinical relevance of OMBC in pulmonary metastasectomy of recurrent breast cancer. We also investigated lung metastases for the prevalence of CD44+/CD24-/low tumor cells and evaluated their prognostic significance. We reviewed data from a registry of breast cancer patients with lung metastases who underwent pulmonary metastasectomy at Jikei University Hospital. We analyzed prognostic factors for overall survival (OS) and progression-free survival (PFS) after metastasectomy and examined the prognostic difference between OMBC and non-OMBC patients. CD44+/CD24-/low tumor cells were detected by immunohistochemical analysis of lung metastases sites. Among 17 breast cancer patients with lung metastasis, 5-year OS and PFS rates were 72 and 36 %, respectively. Better OS was observed among patients with OMBC. Patients with OMBC, estrogen receptor-positive cells, and disease-free intervals of >8 years had better PFS. The presence of CD44+/CD24-/low tumor cells influenced progression after lung metastasectomy, with median PFS of only 6 months in patients with a high prevalence of cancer-initiating cells. CD44+/CD24-/low cells with cancer-initiating properties were present in only 9 % ± 3 of patients with OMBC, but were found in 73 % ± 12 of patients with non-OMBC. Pulmonary metastasectomy may be a treatment option for OMBC patients with lung metastases. Better prognosis of OMBC may be associated with low levels of cancer-initiating cells.

[The current status of home palliative care for patients with advanced cancer at the Jikei University School of Medicine].

Medical oncologists are involved in cancer chemotherapy as well as end-of-life care. Recently, an increased number of patients with advanced cancer have expressed their preference to receive palliative care at their home during the end-of-life period, and several home medical care providers have aimed to provide such a service. The number of cancer patients who wish to receive home palliative care has also increased at our institution. We reviewed the characteristics of advanced cancer patients who received chemotherapy and who eventually received homecare from 2012 to 2014. The total number of patients was 22. Of these, 9 had breast cancer(40.9%)and 8 had colorectal cancer(36.4%). The median age was 68(range 36-90) years. Half of these patients died at home. The median duration of homecare to death was 64.5(range 12-252)days. Approximately 70% of patients were able to remain at home for over a month, but 3 patients died within 2 weeks at home and 1 patient returned to the hospital after 10 days of homecare due to disease progression. While palliative care in the home setting is valued by many cancer patients in the end-of-life period, close monitoring is needed for patients with rapidly progressing disease.

Tele-education by an orthopedic specialist increased the confidence in orthopedics of a general practitioner at a rural solo-practice clinic.

Objective: General practitioners in rural clinics are required to deal with musculoskeletal problems, but they often lack the confidence. We aim to confirm changes in their confidence in orthopedic practices after using tele-education. Materials and Methods: We conducted tele-education in orthopedic practices from June 1, 2022, to November 30, 2022. Using a teleconference system, the first author, an orthopedic specialist, provided tele-education training to an independent general practitioner in a rural clinic. We adopted a 7-point Likert scale to assess the general practitioner's confidence levels. In pre- and post-research, the counts and confidence levels in the scale were assessed for 18 types of orthopedic practices each month. Furthermore, we interviewed the general practitioner to examine the factors influencing their confidence. Results: The confidence levels increased for all measurement items. The most experienced orthopedic practice was "Advising on daily care for musculoskeletal problems", with confidence levels increasing from 3 to 6. The least experienced orthopedic practice was "Manipulative reduction of radial head subluxation", with confidence levels increasing from 4 to 5. The factors that influenced the change in confidence levels were regular feedback and unrestricted availability of consultations. Conclusion: Tele-education in orthopedics may enhance general practitioners' confidence in orthopedic practices.

Analysis of Bovine Lactoferrin in Infant Formula and Adult Nutritional Products by Optical Biosensor Immunoassay: Collaborative Study, Final Action AOAC 2021.07.

BACKGROUND: Bovine lactoferrin is increasingly being used as an ingredient in infant formula manufacture to enhance nutritional efficacy through the provision of growth, immunoprotective and antimicrobial factors to the neonate. OBJECTIVE: To evaluate method reproducibility of AOAC 2021.07 Official First Action method for compliance with the performance requirements described in Standard Method Performance Requirement (SMPR®) 2020.005. METHOD: Eight laboratories participated in the analysis of blind-duplicate samples of seven nutritional products. Samples were diluted in buffer, and an optical biosensor immunoassay was used in a direct assay format to quantitate bovine lactoferrin by its interaction with an immobilized anti-lactoferrin antibody. Quantitation was accomplished by the external standard technique with interpolation from a 4-parameter calibration regression. RESULTS: After outliers were removed, precision as reproducibility was found to be within limits set in SMPR 2020.005 (≤ 9%) for six out of seven samples and all had acceptable HorRatR values ranging from 1.0 to 2.1. Additionally, comparison with an alternative independent Stakeholder Panel on Infant Formula and Adult Nutritionals (SPIFAN) First Action method (heparin clean-up LC UV), showed negligible difference between results. CONCLUSIONS: The method described is suitable for the quantification of intact, undenatured bovine lactoferrin in powdered infant formulas. The SPIFAN Expert Review Panel evaluated the method and accompanying validation data from this multi-laboratory testing study in July 2023 and recommended Official Method 2021.07 for adoption as a Final Action Official Method. HIGHLIGHTS: A multi-laboratory validation study of an automated optical biosensor immunoassay for the determination of intact, undenatured bovine lactoferrin is described.

Complete response of esophageal small cell carcinoma amrubicin treatment.

Small cell carcinoma of the esophagus (SmCCE) is a rare and aggressive disease known to have a poor prognosis. SmCCE patients are generally treated with a chemotherapeutic regimen for small cell lung cancer. Salvage therapy for patients with relapsed or refractory tumors has not yet been established. A 63-year-old man with extensive SmCCE was treated with chemotherapy consisting of cisplatin (CDDP) and irinotecan (CPT-11). After the second course of CPT-11/CDDP, the celiac lymph node increased in size. Amrubicin (AMR) as second-line chemotherapy was started. The patient had a complete response after the fifth course of AMR, resulting in an 8-month progression-free survival after initial administration. This case suggests that, as in small cell lung cancer, AMR is effective for SmCCE.

Takayasu arteritis presenting with fever of unknown origin and bilateral carotid artery tenderness: A case report.

A 51-year-old otherwise healthy woman was referred to our hospital with a fever of unknown origin, liver dysfunction, and anemia. One month prior, she had persistent and spontaneous anterior neck pain, with no exacerbation during swallowing or neck movements. Physical examination revealed no pharyngeal or tonsillar abnormalities, heart murmur, arthritis, skin rash, or lymphadenopathy, except for mild bilateral common carotid artery tenderness at the level of the thyroid cartilage. Blood tests showed nonspecific chronic inflammatory findings, anemia, and liver damage, whereas blood cultures, viral antibodies, interferon-γ release assay, and antibodies specific for any collagen disease showed negative results. Echocardiography and computed tomography without contrast of the neck, chest, abdomen, and pelvis showed no apparent abnormalities. She was subsequently diagnosed with Takayasu arteritis using positron emission tomography. Identifying a characteristic history of bilateral carotid artery tenderness and subsequent positron emission tomography can be useful for diagnosing Takayasu arteritis.

Evaluation of simulation-based ultrasound education using a bladder simulator for medical students in Japan: a prospective observational study.

PURPOSE: This study aimed to investigate the usefulness of ultrasound education for medical students using a bladder simulator. METHODS: This prospective observational study included volunteer fifth- and sixth-year medical students. An intravesical urine volume measurement simulator and a pocket-sized hand-held ultrasound device were used. The ultrasound education comprised pre-learning, briefing, simulation, debriefing, and learning summary. The simulation consisted of two tests: bladder simulator cube evaluation and scenario-based clinical application. A self-rated confidence score of 0-10 points along with reasons for the scores was recorded before and after the ultrasound education. RESULTS: Twelve participants (median age, 23 years; female, 75%) met the inclusion criteria and were examined. Participants' bladder simulator cube evaluation and scenario-based clinical application test results were good, and the educational difficulty level was appropriate. The mean confidence scores for main unit operation, probe control, image acquisition, image evaluation and clinical application before the ultrasound education were 1.0, 1.8, 1.3, 0.8 and 0.1 points, respectively. The mean confidence scores after the ultrasound education were 5.8, 5.9, 5.4, 5.5 and 5.1, respectively, with significant increases for all items (p < 0.01). The positive impression categories that affected confidence scores after ultrasound education were related to device operation, image acquisition, image evaluation, clinical application and learning. CONCLUSION: Ultrasound education using a bladder simulator increases confidence scores by imparting competencies related to device operation, image acquisition, image evaluation and clinical application, and it improves students' learning impression. This is a useful method for introductory ultrasound education for medical students.

Utilization of and barriers to a telemedicine system at a rural general hospital in Japan: a mixed methods study.

Objective: The initial and operational costs of telemedicine are major barriers to its adoption. We aimed to investigate and identify the barriers to adopting a telemedicine system in a Japanese rural general hospital without incurring setup and operational costs. Materials and Methods: Our study was conducted between May and August 2018, and included six general practitioners working at a rural general hospital. We extracted data collected from messages (date and time, sender and recipient, and counts and contents of messages) and conducted semi-structured interviews, which were then analyzed using quantitative and qualitative methods. Results: We quantitatively analyzed the total counted of the 179 messages. The total counts recorded for each physician were 56 (A), 20 (B), 3 (C), 74 (D), 5 (E), and 21 (F). The mean monthly counts were 2.17 (May), 8.50 (June), 11.50 (July), and 7.67 (August). Interview data from the six physicians yielded 13 codes that included various points of dissatisfaction acting as barriers to using our system, which we grouped into mental and physical barriers. Mental barriers included suspicion of carrying, feelings of isolation, and loss, whereas physical barriers included portability, user authentication, internet speed, group chat system, notice, search image, typing, chat system, print facility, and limited function. Conclusion: The representative barriers to introducing a telemedicine system at a rural general hospital in Japan without initial and running costs could be classified as feelings of isolation and suspicion of carrying (mental barriers); and notice, portability, and user authentication (physical barriers). Continued investigation in this area is warranted, and solutions to these barriers could improve the shortage of medical staff in the context of declining birth rates and aging populations in Japan.

[A case of stage IV b pancreatic cancer in which a catheter-related infection caused by epidural/subcutaneous reservoir therapy affected palliative home-based care].

We report the case of a patient with a stage IV b pancreatic cancer in which epidural/subcutaneous reservoir therapy was effective for pain control. However, a catheter-related infection caused by methicillin-resistant Staphylococcus aureus (MRSA)was occurred. In recent years, the number of cancer patients desiring palliative home-based care in Japan has increased. Epidural/subcutaneous reservoir therapy is often offered to relieve refractory pain, and to reduce the side effects of systemic administration of opioids, such as drowsiness, in homecare patients. We believe that this patient may have been able to continue home-based care if the catheter-related infection did not occur, because a significant improvement was calculated in the pain level by the numerical rating scale(NRS)observed. It is important to establish and share common strict guidelines between hospital doctors and general practitioners for the management of the subcutaneous catheter and reservoir therapy in order to prevent catheter-related infections over a long period.

[Which biomarkers can we use?].

Gene array testing defined the intrinsic biological subtypes including"luminal A", "luminal B", "HER2-enriched" and "basal" within breast cancer. These subtypes may be approximated using clinicopathological immunochemistry rather than gene expression array criteria. These subtypes have different epidemiological risk factors, different natural histories, and different response to systemic and local therapies. Systemic therapy recommendations follow the subtype classification. "Estrogen receptor", "progesterone receptor", "human epidermal growth factor receptor 2" and "Ki67" are the most important biological markers to classify the subtypes and predict the prognosis and the response to the therapy. The new targeting therapy will require new biomarkers.

Analysis of Bovine Lactoferrin in Infant Formula and Adult Nutritional Products by Optical Biosensor Immunoassay: First Action 2021.07.

BACKGROUND: Bovine lactoferrin is increasingly being used as an ingredient in infant formula manufacture to enhance nutritional efficacy through the provision of immunoprotective, growth, and antimicrobial factors to the neonate. OBJECTIVE: To evaluate the analytical performance of an optical biosensor immunoassay for compliance with the method performance requirements described in SMPR 2020.005. METHOD: Following dilution of the sample in buffer, an automated, label-free, real-time optical biosensor immunoassay was used in a direct assay format to quantitate bovine lactoferrin by its interaction with an immobilized anti-lactoferrin antibody. Quantitation was accomplished by the external standard technique with interpolation from a 4-parameter calibration regression. RESULTS: The analytical range (0-200 mg/hg), method detection limit (0.8 mg/hg), recovery (96.1-109.2%), and repeatability (1.0-5.3%) complied with the requirements given in the lactoferrin SMPR. The method was shown to be specific for native, intact lactoferrin; thermally denatured lactoferrin generated no measurable binding response. CONCLUSION: The method described is suitable for the quantification of intact, undenatured lactoferrin in milk products, infant formulas (bovine milk protein-based, soy protein-based, and amino acid-based), and adult nutritionals and has been demonstrated to meet the performance requirements defined in SMPR 2020.005. HIGHLIGHTS: A single-laboratory validation (SLV) of an automated biosensor immunoassay for the determination of intact, undenatured lactoferrin is described.

Non-convulsive epilepsy with acute-onset and short-lasting repeated fatigue attacks: A case of 30-year-old man.

A 30-year-old man was referred to our department because of repeated acute-onset and short-lasting fatigue attacks, which occurred from 3 months before the referral. He had no abnormal findings in blood tests, electrocardiogram (including 24- h monitoring), or head MRI (including angiography). His vital signs were unremarkable, and his physical examination revealed no abnormal findings. Detailed history-taking with closed-ended questions revealed the occurrence of tingling sensation from the right fingers as the aura before his attacks. Electroencephalography was performed, which revealed focal epilepsy. Levetiracetam resolved his symptoms. Physicians could consider non-convulsive epilepsy as a potential cause of repeated acute-onset and short-lasting fatigue attacks of unknown etiology after underlying conditions, such as metabolic diseases, have been ruled out.

A case of juvenile myoclonic epilepsy in which a disease-specific question led to the diagnosis.

A 17-year-old female patient presented to our hospital with repeated transient loss of consciousness lasting less than 10 min. After regaining consciousness, she experienced no disorientation, confusion, tongue-biting, or incontinence. Physical findings, blood tests, electrocardiogram, and echocardiogram showed no obvious abnormalities. On being asked whether she had experienced sudden rapid body movements, she answered "yes." Therefore, we suspected juvenile myoclonic epilepsy (JME) and obtained an electroencephalogram, which showed diffuse bilateral bursts of spike-and-wave complexes, confirming the diagnosis. In adolescent patients with transient loss of consciousness, myoclonic jerks should be actively confirmed for the diagnosis of JME.

A case of Raynaud's phenomenon of toes induced by whole-body warm stimulation.

Raynaud's phenomenon, induced by cold stimulation and emotional stress, is also induced by whole-body warm stimulation. A 74-year-old man was referred to our department because of nocturnal toe pain from 2 years prior and immediate color change of the toes from 1 year prior when submerging himself into a warm bath. Physical examination and blood tests revealed no abnormal findings suggestive of secondary Raynaud's phenomenon. Two years later, the signs and symptoms persisted. When physicians confirm Reynaud's phenomenon, they should check for the possibility of secondary Reynaud's phenomenon. Additional research on Reynaud's phenomenon induced by warm stimulation is needed.

Severe edema and blood blisters of the lower extremities caused by sitagliptin, a dipeptidyl peptidase-4 inhibitor.

Severe edema and blood blisters can occur as adverse events associated with sitagliptin. A history of dipeptidyl peptidase-4 inhibitors should be considered when examining patients with edema and blood blisters of uncertain cause.

Pseudo-fever caused by predictive electronic thermometers: A case report.

A 33-year-old man was referred to our hospital with chief complaints of fever, dizziness, and headache. Although he had recurring fever and dizziness for 7 months, neurological examination, magnetic resonance imaging, computed tomography, electrocardiograms, and blood tests were normal. He was diagnosed with functional hyperthermia, cervical vertigo, and tension headache and was treated with oral medication and physical therapy. After treatment, the dizziness and headache resolved; however, the fever and anxiety did not. During follow-up, he noticed differing results from different electronic thermometers. The physician decided to use an accurate analog thermometer, a gallium thermometer, in combination with the other thermometers. The results differed significantly among the thermometers, and the electronic thermometer readings were found to be inappropriately high. The physician made a diagnosis of pseudo-fever, and the patient recognized that the gallium thermometer's results were the most accurate reflection of his physical condition, resolving his anxiety.

Functional hyperthermia caused by obstructive sleep apnea syndrome: A case report.

A 47-year-old farm worker with diabetes mellitus, dyslipidemia, and hyperuricemia was referred to our hospital for a 3-month history of fever and malaise. He had no respiratory tract or abdominal symptoms, skin rashes, or joint pain. There was no change to his regular medication or pesticide exposure. Blood tests and echocardiography revealed no abnormalities. Whole-body computed tomography revealed a fatty liver; however, non-alcoholic steatohepatitis was excluded. We diagnosed the patient with functional hyperthermia. He had a history of snoring and weight gain, and we suspected the obstructive sleep apnea syndrome to be a stressor. Polysomnography revealed severe obstructive sleep apnea syndrome with an apnea-hypopnea index of 44.5. Continuous positive airway pressure was introduced; the axillary temperature decreased gradually and malaise was resolved. Functional hyperthermia should be considered a cause of fever with a negative inflammatory response. Obstructive sleep apnea syndrome can be a stressor for functional hyperthermia, which can be improved by interventions.