The comparison of the clinical outcomes and costs between surgical aortic valve replacement and transcatheter aortic valve implantation based on the Japanese Diagnosis Procedure Combination database.

PURPOSE: We evaluated the clinical outcomes and costs of surgical aortic valve replacement (SAVR) and transfemoral transcatheter aortic valve implantation (TAVI) for aortic stenosis using the Japanese Diagnosis Procedure Combination (DPC) database. METHODS: Using our extraction protocol, we retrospectively analyzed summary tables in the DPC database from 2016 to 2019, which were provided by the Ministry of Health, Labor and Welfare. A total of 27,278 patients were available (SAVR, n = 12,534; TAVI, n = 14,744). RESULTS: The TAVI group was older than the SAVR group (SAVR vs. TAVI: 74.6 vs. 84.5 years; P < 0.01), with a lower in-hospital mortality (1.0 vs. 0.6%; P < 0.01) and a shorter hospital stay (26.9 vs. 20.3 days; P < 0.01). TAVI conferred more total medical service reimbursement points than SAVR (493,944 vs. 605,241 points; P < 0.01), especially materials points (147,830 vs. 434,609 points; P < 0.01). Total insurance claims for TAVI were approximately 1 million yen higher than those for SAVR. Regarding the details of costs, only the operation cost was higher, while other costs were lower with TAVI than with SAVR. CONCLUSION: Our analysis revealed that both SAVR and TAVI showed acceptable clinical outcomes. TAVI was associated with higher total insurance claims than SAVR. If the material cost of TAVI operations can be reduced, greater cost-effectiveness can be expected.

Cytological features of stromal spindle cells and their prognostic significance in lung adenocarcinoma.

INTRODUCTION: Cancer-associated fibroblasts (CAFs) in the tumour microenvironment play a key role in tumour development, proliferation, invasion, and metastasis. The cytological features of spindle cells including CAFs-defined as stromal spindle cells (SSCs) adjacent to cancer cells-are frequently encountered in pulmonary adenocarcinomas. This study aimed to investigate the association between the presence of SSCs in cytological specimens and the clinicopathological features. METHODS: We evaluated 211 patients with pulmonary adenocarcinoma who underwent surgical resection. All participants had cytological specimens corresponding to the histological specimens available for review. RESULTS: Of the 211 cases examined, 89 were SSC-positive (SSC+ ) and 122 were SSC-negative (SSC- ). SSC+ cases were more frequently associated with higher pathological stage (P < 0.001), lymph node metastasis (P = 0.002), anaplastic lymphoma kinase (ALK) gene rearrangement (P = 0.04), high tumour grade (P < 0.001), solid and micropapillary predominant pattern (P = 0.02), and lymphatic vessel (P = 0.003), blood vessel (P < 0.001), and pleural invasion (P = 0.03) as compared to SSC- cases. Patients with SSC+ adenocarcinoma had a significantly shorter recurrence-free survival than those with SSC- adenocarcinoma (P = 0.009). Cytologically, necrotic background (P = 0.002), mucinous cancer cells (P = 0.02), pleomorphic cells (P < 0.001), and mutual cell inclusions (P = 0.01) were observed more frequently in SSC+ adenocarcinomas. CONCLUSIONS: The presence of SSCs could be an important cytological feature for predicting poor prognosis in lung adenocarcinomas.

Validity of a model using routinely collected data for identifying infections following gastric, colon, and liver cancer surgeries.

PURPOSE: Validating outcome measures is a prerequisite for using administrative databases for comparative effectiveness research. Although the Japanese Diagnosis Procedure Combination database is widely used in surgical studies, the outcome measure for postsurgical infection has not been validated. We developed a model to identify postsurgical infections using the routinely collected Diagnosis Procedure Combination data. METHODS: We retrospectively identified inpatients who underwent surgery for gastric, colon, or liver cancer between April 2016 and March 2018 at four hospitals. Chart reviews were conducted to identify postsurgical infections. We used bootstrap analysis with backwards variable elimination to select independent variables from routinely collected diagnosis and procedure data. Selected variables were used to create a score predicting the chart review-identified infections, and the performance of the score was tested. RESULTS: Among the 746 eligible patients, 96 patients (13%) had postoperative infections. Three variables were identified as predictors: diagnosis of infectious disease recorded as a complication arising after admission, addition of an intravenous antibiotic, and bacterial microscopy or culture. The prediction model had a C-statistic of 0.885 and pseudo-R2 of 0.358. A cut-off of one point of the score showed a sensitivity of 92% and specificity of 72%, and a cut-off of two points showed a sensitivity of 75% and specificity of 91%. CONCLUSIONS: Our model using routinely collected administrative data accurately identified postoperative infections. Further external validation would lead to the application of the model for research using administrative databases.

Simultaneous occurrence of accelerated nodulosis in lungs, liver, and kidneys, and acute exacerbation of interstitial pneumonia in a patient with rheumatoid arthritis: an autopsy case report.

BACKGROUND: Accelerated nodulosis (ARN) is a rare variant of rheumatoid nodules (RNs) that is characterized by a rapid onset or the worsening of RNs. It generally develops at the fingers in patients with rheumatoid arthritis (RA) receiving methotrexate (MTX). Few case reports have described ARN at an extracutaneous location. CASE PRESENTATION: An elderly patient with long-standing RA was admitted to our hospital with acute respiratory failure. Computed tomography upon admission showed diffuse ground-glass opacities superimposed with subpleural reticular shadowing and honeycombing and multiple nodules in the lungs and liver. Despite the discontinuation of MTX and introduction of an immunosuppressive regimen with pulse methylprednisolone followed by a tapering dose of prednisolone and intravenous cyclophosphamide, the patient died due to the acute exacerbation (AE) of RA-related interstitial lung disease (ILD) following the parallel waxing and waning of a diffuse interstitial shadow and pulmonary and liver nodules. At autopsy, RNs were scattered throughout both lung fields in addition to extensive interstitial changes. RNs were also detected in the liver and kidneys. The foci of cryptococcosis were mainly identified in alveolar spaces. Based on the clinical and pathological findings, these nodules were most consistent with ARN because of acute increases in the size and number of previously detected pulmonary nodules. CONCLUSION: The present case is noteworthy because ARN was concurrently detected in multiple internal organs and may be associated with the AE of RA-related ILD.

Ultrasonographic test for detecting the chiasma plantare formation between the flexor hallucis longus and flexor digitorum longus.

PURPOSE: Flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons are frequently used in surgery. Therefore, it is necessary to evaluate the chiasma plantare formation preoperatively. The development of ultrasonography (US) may help the chiasma plantare formation evaluation. The purpose of this study is to prove the usefulness of the US method using cadavers. METHODS: Eleven cases (twenty-two ankles) were obtained from Asian adult cadavers. At first, we evaluated and compared the chiasma plantare formation using US. Later, we evaluated that using the findings after dissection as type A (connection from FHL to FDL of the second toe), type B (connection from FHL to the second and third toes), type C (connection from FHL to the second through fourth toes), or type D (connection from FHL to all lesser toes). RESULTS: Chiasma plantare formation was classified as types A and B in fifteen and seven ankles, respectively. After dissection, chiasma plantare formation was classified as types A, B, and C in fourteen, six, and two ankles, respectively. Therefore, there was an 86% similarity between the two methods. CONCLUSIONS: Chiasma plantare formation can be reliably and noninvasively evaluated using US. This may be useful for preoperative rehabilitation or surgical procedure planning.

[Idiopathic Intrapulmonary Hematoma Need to Differentiate from Pulmonary Metastasis of Malignant Melanoma:Report of a Case].

A 74-year-old man had previously been treated for primary malignant melanoma of the bladder. Three years after surgery, 8 mm round nodule in the right lower lobe was found on chest computed tomography. The nodule increased to 11 mm after three months, and resected with a diagnosis of metastatic malignant melanoma. By pathology, it was diagnosed as an intrapulmonary hematoma.

Frequent appearance of club cell (Clara cell)-like cells as a histological marker for ALK-positive lung adenocarcinoma.

Anaplastic lymphoma kinase-rearranged (ALK+ ) lung cancers show characteristic histological features, such as solid signet ring cell patterns and mucinous cribriform patterns; however, these features are not always observed in ALK+ lung cancers. We noticed that club cell (Clara cell)-like cells (CLCs) were frequently present in the papillary portion of ALK+ lung adenocarcinomas. In this study, we investigated the importance of CLCs in papillary patterns of ALK+ lung cancers. We compared the histological features of 18 ALK+ cases with 62 control cases (22 epidermal growth factor receptor-positive (EGFR+ ) and 40 ALK- and EGFR-negative (ALK- /EGFR- ) cases). The present study analyzed presence of papillary pattern, proportion of papillary pattern area, presence of micropapillary pattern, frequency of CLCs and lengths of snout. The frequency of CLCs in ALK+ cases was significantly higher than that in EGFR+ cases and ALK- /EGFR- cases. Micropapillary pattern was more frequently observed in ALK+ cases than that in ALK- /EGFR- cases (P < 0.001). The present study indicated that the high frequency of CLCs in papillary patterns was significantly associated with ALK+ cases. When solid signet ring cell patterns and mucinous cribriform patterns are absent, the high frequency of CLCs in papillary adenocarcinoma could be a useful histological marker for ALK+ lung cancers.

IFN-ß Improves Sepsis-related Alveolar Macrophage Dysfunction and Postseptic Acute Respiratory Distress Syndrome-related Mortality.

IFN-ß is reported to improve survival in patients with acute respiratory distress syndrome (ARDS), possibly by preventing sepsis-induced immunosuppression, but its therapeutic nature in ARDS pathogenesis is poorly understood. We investigated the therapeutic effects of IFN-ß for postseptic ARDS to better understand its pathogenesis in mice. Postseptic ARDS was reproduced in mice by cecal ligation and puncture to induce sepsis, followed 4 days later by intratracheal instillation of Pseudomonas aeruginosa to cause pneumonia with or without subcutaneous administration of IFN-ß 1 day earlier. Sepsis induced prolonged increases in alveolar TNF-α and IL-10 concentrations and innate immune reprogramming; specifically, it reduced alveolar macrophage (AM) phagocytosis and KC (CXCL1) secretion. Ex vivo AM exposure to TNF-α or IL-10 duplicated cytokine release impairment. Compared with sepsis or pneumonia alone, pneumonia after sepsis was associated with blunted alveolar KC responses and reduced neutrophil recruitment into alveoli despite increased neutrophil burden in lungs (i.e., "incomplete alveolar neutrophil recruitment"), reduced bacterial clearance, increased lung injury, and markedly increased mortality. Importantly, IFN-ß reversed the TNF-α/IL-10-mediated impairment of AM cytokine secretion in vitro, restored alveolar innate immune responsiveness in vivo, improved alveolar neutrophil recruitment and bacterial clearance, and consequently reduced the odds ratio for 7-day mortality by 85% (odds ratio, 0.15; 95% confidence interval, 0.03-0.82; P = 0.045). This mouse model of sequential sepsis → pneumonia infection revealed incomplete alveolar neutrophil recruitment as a novel pathogenic mechanism for postseptic ARDS, and systemic IFN-ß improved survival by restoring the impaired function of AMs, mainly by recruiting neutrophils to alveoli.

Incidence of aspiration pneumonia during hospitalization in Japanese hospitalized cases did not increase whereas concern factors were exacerbated in a time-dependent manner: analysis of Diagnosis Procedure Combination (DPC) data.

This study aimed i) to investigate about items with high relevance for aspiration pneumonia during hospitalization among cases evaluated using Diagnosis Procedure Combination data, and ii) to determine whether the concern factors for aspiration pneumonia during hospitalization were exacerbated with the trend of the time. The Diagnosis Procedure Combination data were gathered from 2010 through to 2015 with 63,390 cases at Saga University Hospital. The occurrence of concern factors of aspiration pneumonia during hospitalization were compared in the two time periods set (2010-2012 and 2013-2015). The concern factors included: male, age, dysphagia at admission and during hospitalization, use and days in the emergency care unit or high care unit, use of the intensive care unit, and use of an ambulance. Age, dysphagia, and use of the intensive care unit were time-dependently exacerbated. The incidence of aspiration pneumonia during hospitalization in hospitalized cases did not differ between years 2010-2012 and 2013-2015. Aspiration pneumonia during hospitalization complicated with surgery and number days in the emergency care unit or high care unit diminished in years 2013-2015. Despite an increased concern of aspiration pneumonia during hospitalization, the complication rate of aspiration pneumonia during hospitalization did not increase.

Diagnostic utility of BAP1 and EZH2 expression in malignant mesothelioma.

AIMS: Malignant mesothelioma is a highly aggressive cancer that is usually diagnosed at advanced stages; thus, highly sensitive and specific markers are necessary for its early definitive diagnosis. The aim of this study was to evaluate the diagnostic utility and prognostic significance of BAP1 and EZH2 in malignant mesothelioma. METHODS AND RESULTS: The expression of BAP1 and EZH2 was investigated by immunohistochemistry in 32 malignant mesotheliomas and 44 benign mesothelial proliferative lesions, including well-differentiated papillary mesothelioma (n = 4), mesothelial inclusion cyst (n = 22), and reactive mesothelial hyperplasia (n = 18). BAP1 loss and high EZH2 expression were observed in 17 (53%) and 22 (66%) malignant mesothelioma cases, respectively, whereas none of the benign lesions showed BAP1 loss or high EZH2 expression. The combination of BAP1 loss and high EZH2 expression as markers to differentiate epithelioid/biphasic malignant mesothelioma from benign mesothelial lesions was highly sensitive (90%) and specific (100%). There were no statistically significant associations between parameters such as age and sex of patients, tumour location, asbestos exposure, treatment, histology, and BAP1 or EZH2 expression. Survival analysis revealed that BAP1 loss, but not high EZH2 expression, was associated with a better prognosis. CONCLUSIONS: BAP1 loss and high EZH2 expression were highly specific to malignant mesothelioma in differentiating it from benign mesothelial proliferations, and the combination of these two markers improved the diagnostic accuracy.

Predictors of long-term compensatory response of pulmonary function following major lung resection for non-small cell lung cancer.

BACKGROUND AND OBJECTIVE: Long-term pulmonary function which might include compensatory response (CR) significantly influences quality of life of long-term survivor after major lung resection. We investigated long-term pulmonary function after major lung resection. METHODS: A total of 137 patients who had undergone lobar resection for non-small cell lung cancer (NSCLC) from May 2013 to June 2014 had spirometry at 10-14 months after surgery. Actual post-operative forced expiratory volume in 1 s (FEV1 ) (FEV1apo )/predicted post-operative FEV1 (FEV1ppo ), actual post-operative forced vital capacity (FVC) (FVCapo )/predicted post-operative FVC (FVCppo ), its relationship with clinicopathological factors and immunohistochemistry for pro-surfactant protein C (pro-SPC), thyroid transcription factor-1 (TTF-1) and vascular endothelial growth factor receptor 2 (VEGFR2) were investigated. RESULTS: FEV1apo /FEV1ppo showed strong correlation with FVCapo /FVCppo (r = 0.628; P < 0.001). We defined greater CR as both FEV1apo /FEV1ppo and FVCapo /FVCppo were >120%. Greater CR was significantly associated with decreased smoking index (P < 0.001) and greater resected subsegments (P = 0.037). The never-smoker group revealed significantly greater CR compared with the smoker group in both FEV1apo /FEV1ppo (119.9 ± 12.5% vs 107.5 ± 14.2%; P = 0.030) and FVCapo /FVCppo (117.9 ± 9.98% vs 107.2 ± 13.1%; P = 0.046) in case-matched comparison. The expression of pro-SPC, TTF-1 and VEGFR2 in the normal lung parenchyma of greater CR group was significantly higher than those of lesser CR group (P < 0.001 for each). In addition, pro-SPC, TTF-1 and VEGFR2 expressions showed a significant correlation to the degree of CR especially in the smoker group (r = 0.631, 0.705 and 0.732, respectively; P < 0.001 for each). CONCLUSION: Our data suggest that smokers may develop lesser long-term CR after major lung resection. Decreased expression of pro-SPC, TTF-1 and VEGFR2 may indicate decreased capacity of CR, especially in patients who smoke.

[Prevention and Treatment of Mediastinitis Following Cardiac Surgery].

Mediastinitis after cardiac surgery occurs about 1% of the time and is associated with adverse effects on both short- and long-term outcomes. Therefore, prevention of mediastinitis is very important. However, when this complication occurs, a radical cure should be performed using a safe and reliable method. Many pre-, intra-, and post-operative risk factors have been reported. Perioperative management based on an understanding of the pathological condition that causes this complication is an effective prevention strategy. Early detection and treatment are most important, and there should be close coordination with plastic surgeons. Recently, negative pressure wound therapy has been used widely and appears to be effective for this complication.

Usefulness of Intraoperative Cone Beam CT Images on Video-assisted Thoracic Surgery.

For the resection of pulmonary ground glass opacity (GGO) or non-palpable nodule on video-assisted thoracic surgery (VATS), preoperative computed tomography (CT)-guided VATS marker pricking is usually performed. Recently, air embolisms after VATS marker pricking have been reported to be serious problems. The purpose of this study was to evaluate the usefulness of intraoperative cone beam CT images on VATS to avoid preoperative VATS marker pricking. The CT number of the both GGO and nodule indicate the range from -200 to -800 HU in general. We evaluated the detection ability of the lesion in seven elements and the simulated lungs. The result indicated that there was a linear equation of "y=1.0599×-2.1492" and the degree of correlation was "R2=0.9826" for the relationship between CT number and W number [voxel number in cone beam computed tomography (CBCT)]. Evaluation of low contrast resolution has been performed. The contrast noise ratios were 2.86 on CBCT and 1.50 on multi detector-row computed tomography (MDCT), while the relative contrast ratios were same both on CBCT and MDCT (0.19) as the lowest CT number (-700 HU). In clinical situation, four types of pulmonary lesions (pure GGO, mixed GGO, solid nodule, and cyst) were detected on MDCT, and intraoperative CBCT could identify all lesions as same configuration as on MDCT. The contrast noise ratio (CNR) and relative contrast ratio (RCR) could not admit the significant difference. In conclusion, the intraoperative CBCT can be used as a non-invasive image navigator for VATS, and the preoperative CT-guided VATS marker pricking can be avoided.

Infectious disease during hospitalization is the major causative factor for prolonged hospitalization: multivariate analysis of diagnosis procedure combination (DPC) data of 20,876 cases in Japan.

This study aimed to evaluate causative factors for prolonged hospitalization based on hospitalization status, type of hospital ward, and comorbidities, specifically diabetes mellitus and infectious diseases, in 20,876 patients hospitalized in Saga University Hospital from April 1, 2012, to February 28, 2015. Prolonged hospitalization was defined as hospital days exceeding period 3 in the diagnosis procedure combination system. Among all factors, causative (risk) factors for prolonged hospitalization were evaluated by multiple logistic regression analysis. Multivariate analysis indicated causative factors for prolonged hospitalization were aging, comorbid diabetes mellitus, time spent in the intensive care unit, and infectious diseases contracted during hospitalization. The risk factors for contracting infectious diseases during hospitalization were aging, male sex, comorbid diabetes mellitus, and increased number of days spent in period 3 in the diagnosis procedure combination code. These data indicated that critical factors for discharge from hospital within an appropriate time frame were prevention of infectious diseases during hospitalization, and a fast and effective therapeutic approach to patients in the intensive care unit.

[INTRODUCTION OF LESS-INVASIVE CARDIOVASCULAR SURGICAL PROCEDURES AND PERIOPERATIVE CARE IN OLDER PATIENTS].

The intravascular approach to cardiovascular surgery is extending the indications for the aging population. Because transaortic aortic valve replacement does not require opening the chest, the procedure benefits high-risk patients including the elderly. The introduction of open stenting to distal arch replacement and the hybrid approach to thoracoabdominal aneurysm repair significantly reduced surgical invasiveness. Well-established beating-heart surgery for coronary artery bypass grafting has become common in Japan. It is also contributing to reducing the risk to the aging population. Meticulous perioperative care for older patients, especially screening for vascular complications, is mandatory. Arterial diseases including those of the coronary, cerebrovascular, and peripheral arteries frequently occur in the elderly. The precise identification of risk factors and adequate perioperative care of complications are keys to the successful management of older patients who undergo cardiovascular surgery.

Digestibility of new dietary fibre materials, resistant glucan and hydrogenated resistant glucan in rats and humans, and the physical effects in rats.

Resistant glucan (RG) and hydrogenated resistant glucan (HRG) are newly developed non-digestible carbohydrate materials that decrease lifestyle-related diseases. The bioavailability of RG and HRG was investigated by in vitro experiments using human and rat small intestinal enzymes and by in vivo experiments using rats in the present study. Oligosaccharides, which are minor components of RG and HRG, were hydrolysed slightly by small intestinal enzymes of humans and rats, and the hydrolysing activity was slightly higher in rats than in humans. The amount of glucose released from HRG was greater than that from RG. However, the high-molecular-weight carbohydrates of the main components were hardly hydrolysed. Furthermore, neither RG nor HRG inhibited disaccharidase activity. When rats were raised on a diet containing 5 % of RG, HRG, resistant maltodextrin or fructo-oligosaccharide (FOS) for 4 weeks, all rats developed loose stools and did not recover during the experiment, except for the FOS group. Body weight gain was normal in all groups and was not significantly different compared with the control group. Caecal tissue and content weights were significantly increased by feeding RG or HRG, although other organ and tissue weights were not significantly different among the groups. In conclusion, RG and HRG consist of small amounts of glucose and digestible and non-digestible oligosaccharides, and large amounts of glucose polymers, which were hardly hydrolysed by α-amylase and small intestinal enzymes. RG and HRG, which were developed newly as dietary fibre materials, had no harmful effects on the growth and development of rats.

[Intraoperative Endoscopic Evaluation of the Aortic Valve in Aortic Valve Repair].

This report discusses intraoperative endoscopic evaluation of the aortic valve performed in 2 cases of aortic valve repair. The "direct" or real image by the endoscopy helped to confirm the preoperatively-known lesion and even to detect a new legion which was not detected preoperatively. The endoscopy also enabled the evaluation of the aortic valve under the pressure-loaded condition without releasing the aortic clamp. Postoperative aortic regurgitation was grade I or less in both cases, although it progressed to grade II at 1 year in case 2. Echocardiographic parameters demonstrated no change in the size of the aortic root configuration for 8 and 5 years in case 1 and case 2, respectively. Intraoperative aortic endoscopy was useful to define the pathogenesis of aortic regurgitation and to evaluate the cusp repair procedures, which may contribute to a good mid-term result of aortic valve repair.

Operative technique for tracheo-innominate artery fistula repair.

Tracheo-innominate artery fistula is fatal unless treated surgically. We describe our surgical approach and results in seven patients. The average patient age was 15.7 years; all patients had prior severe neurological deficits. Three of seven patients were in hemorrhagic shock; control of preoperative bleeding was achieved with tracheostomy tube cuff overinflation. The innominate artery and the trachea were exposed through a collar incision and partial upper sternotomy. The innominate artery was divided at the aortic arch and at the bifurcation, with one exception. Cerebral blood flow was monitored by the blood pressure difference in the bilateral upper extremities and by near-infrared spectroscopy. The tracheal fistula was left adherent to the innominate artery in all but one patient. All patients were discharged without new neurologic deficits or severe morbidity. Overall survival was 84% at 37 months, without any vascular, tracheal, or neurological events.

Stromal miR-21 is more important than miR-21 of tumour cells for the progression of gastric cancer.

BACKGROUND: Gastric cancer (GC) is a common cancer globally. miRNA-21 (miR-21) appears to be important in the tumourigenesis of almost all types of human cancer. However its precise localization in GC has yet to be clarified. We thus examined miR-21 localization in GC and revealed its clinicopathological importance. METHODS: Tissue arrays of 469 GCs from 454 patients were examined for miR-21 using in situ hybridization (ISH). The positivity was evaluated separately in tumour cells and stromal cells. Conventional sections of 10 GCs were also stained. Eight cases were examined by quantitative RT-PCR (qRT-PCR). RESULTS: miR-21 was highly expressed in tumour cells of 44% of cases and in cancer stroma of 51% of cases. miR-21 of tumour cells was not related to clinicopathological factors, whereas stromal miR-21 was related to many factors including tumour stage, size, and nodal metastasis. Stromal miR-21 gradually increased during tumour progression. ISH of whole sections showed stronger stromal positivity in invasive areas with desmoplastic reaction. Cancer stroma also showed higher miR-21 expression than tumour and non-tumourous tissue in the qRT-PCR study. CONCLUSION: Stromal miR-21 is closely related to tumour progression in GC. Stromal miR-21 of tumours might be a target of treatment.