Influence of doctor-patient relationships and health-related factors on the medical satisfaction of patients with Sjögren's disease.

OBJECTIVES: Patients with chronic, incurable conditions rely on their providers to help relieve their symptoms. Dissatisfaction with their care can erode the doctor-patient relationship and reduce the effectiveness of treatment. We investigated the relationships between satisfaction and symptoms, the doctor-patient relationship, and health-related factors in patients with Sjögren's disease (SjD) in Japan. METHODS: Using a questionnaire survey, we evaluated via multinomial logistic regression associations between satisfaction [satisfied, neither (neither satisfied nor dissatisfied), dissatisfied] and symptoms, prescribed medications, anxiety, distress, expectations from treatments, and doctor-patient relationships. RESULTS: Of 259 patients, 101 (39%) were satisfied, 111 (42.9%) were neither, and 47 (18.2%) were dissatisfied. Patients who were neither or dissatisfied with their current treatment wanted their systemic pain to disappear (adjusted relative risk ratio [aRRR] 3.38, 95% CI 1.66-6.91; aRRR 3.04, 95% CI 1.30-7.15, respectively). Patients who used artificial saliva only were significantly more dissatisfied (aRRR 3.52, 95% CI 1.03-2.04). Both the neither and dissatisfied patients dissatisfied with their doctor's limited understanding of SiD (aRRR 12.69, 95% CI 4.21-38.24; aRRR 32.76, 95% CI 10.09-106.34, respectively) and with the limited opportunities to ask their doctor about their disease (aRRR 0.19, 95% CI 0.06-0.59; aRRR 0.08, 95% CI 0.02-0.24, respectively). CONCLUSIONS: Pain and the use of artificial saliva alone markedly affected medical satisfaction and we expected the future advance in these two areas, pain and dryness, will improve satisfaction. It is most important for doctors to better understand SjD.

Incidence of acute kidney injury and decreased estimated glomerular filtration rate according to the site of cancer.

BACKGROUND: The epidemiology of renal impairment in patients with cancer remains unclear. We aimed to clarify associations between various cancer sites and renal impairment. METHODS: We reviewed data from 5674 patients aged ≥ 18 years receiving cancer treatment at a single hospital facility. The primary endpoints were the occurrence of acute kidney injury (AKI), a 30% decrease in the estimated glomerular filtration rate (eGFR), or death. Survival time was defined as the time from study enrolment to AKI occurrence. Kaplan-Meier and Cox proportional hazard analyses were performed. RESULTS: Hazard ratios (HRs) for AKI occurrence and a ≥ 30% decline in eGFR were significantly higher for kidney, urinary tract, pancreatic, liver, and gallbladder cancers than for colon cancer. Compared with colon cancer, digestive tract cancer showed a significantly higher HR for AKI occurrence alone. The HRs for a ≥ 30% decline in eGFR were significantly higher for patients aged 71‒77 years or ≥ 78 years than for those aged < 68 years, and for patients with eGFR ≥ 90 mL/min/1.73 m2 or 30-44 mL/min/1.73 m2 than for those with eGFR = 45‒59 mL/min/1.73 m2. CONCLUSIONS: Kidney, urinary, hepatobiliary, or pancreatic cancer are associated with a higher risk of AKI development and eGFR decrease than other cancers. Renal function changes should be more closely monitored in patients with these cancers.

A case of maxillary cancer treated by intra-arterial therapy using a steerable microcatheter.

We report on a 69-year-old man with locally-advanced left maxillary sinus cancer who underwent treatment with intra-arterial chemoradiotherapy. Angiography showed that the main feeding arteries were the left maxillary artery and the ophthalmic artery, arising from the internal carotid artery. Due to acute branching of the ophthalmic artery, conventional microcatheters could not be inserted. Using a steerable microcatheter, we were able to repeatedly administer chemoradiotherapy via the ophthalmic artery. The tumor has mostly disappeared after intra-arterial chemoradiotherapy, and the patient is still alive two years after treatment. A steerable microcatheter is very useful for acute-angled vascular branches.

Factors associated with delayed diagnosis of Sjögren's syndrome among members of the Japanese Sjögren's Association for Patients.

OBJECTIVES: The heterogeneous nature of the signs and symptoms of Sjögren's syndrome (SS) often causes delays in diagnosis. The reasons for these delays have not been investigated in Japan and need to be determined. METHODS: We conducted a questionnaire survey of members of the Japanese Sjögren's Association for Patients (JSAP). Questionnaire items were demographic (sex, age at diagnosis and current age) and factors associated with delayed diagnosis (age at first visit to hospital or clinic, medical department first attended, and initial symptoms). Patients were classified into those diagnosed in <1 year and those diagnosed in ≥1 year. RESULTS: Of the 510 patients questioned, 276 returned the questionnaire, and 255 questionnaires were assessed. The average time to diagnosis was 3.47 years. After adjustment, risk factors for delayed diagnosis were initial visit to an internal medicine department [adjusted odds ratio (aOR) 3.13, 95% confidence interval (CI) 1.42-6.92] or ophthalmology department (aOR, 2.63, 95% CI 1.07-6.50), younger age at initial visit to hospital or clinic (aOR, 0.96, 95% CI 0.94-0.99), and having symptoms of only dry eye (aOR, 2.69, 95% CI 1.09-6.64). Diagnosis was faster when patients had a dry mouth (aOR, 0.55, 95% CI 0.30-1.00) or cutaneous symptoms (aOR, 0.29, 95% CI 0.11-0.82). CONCLUSIONS: Risk factors for delayed SS diagnosis were younger age, initial visit to internal medicine or ophthalmology department, and having only dry eye. We need to raise awareness of SS among doctors and the general public to improve early diagnosis and therapeutic potential.

Volume-rendered computed tomography images of the surgical field for endolymphatic sac surgery.

PURPOSE: Identification of the endolymphatic sac has failed occasionally. Postoperative complications have also rarely been reported. Given a safer and more reliable surgery, preoperative anatomical assessments are valuable, however, the vestibular aqueduct has seldom been seen with multi-planar reconstruction (MPR) computed tomography (CT) images yet. Our study aimed to determine the significance and utility of volume-rendered (VR) CT images of the surgical field for identifying the vestibular aqueduct, compared with MPR CT images. SUBJECTS AND METHODS: 14 patients with Meniere's disease who underwent endolymphatic sac surgery between 2008 and 2011. Location and size of the vestibular aqueduct were assessed using VR and MPR CT images, independently. RESULTS: Accuracy of identifying the location differed significantly between VR and MPR CT images (rate of total correct evaluations: 100% by VR CT images vs 75% by MPR CT images, p = 0.02). Size was correctly identified in cases with a small endolymphatic sac using VR CT images (rate of total correct evaluations for size of the vestibular aqueduct: 100% by VR CT vs 57% by MPR CT, p = 0.046). VR CT images also demonstrated clearly the relationship between the endolymphatic sac and high jugular bulb. In two cases, the endolymphatic sac was identified by VR images, not by MPR images. CONCLUSION: Accurate information about the location and size of vestibular aqueduct can allow sac surgeons to identify a tiny endolymphatic sac more easily and certainly, and also aids surgical trainees to learn sac surgery safely.

Five-year postoperative outcomes of modified staged canal wall up tympanoplasty for primary acquired cholesteatoma.

OBJECTIVE: For successful canal wall up tympanoplasty (CWUT) for the treatment of cholesteatoma, the restoration of stable middle ear aeration is also important; however, little is known about the dynamics of such aeration or the optimal surgical procedure. In this study, alternative additional surgical procedure was selected based on the grade of middle ear aeration during the second-stage operation. SUBJECTS AND METHODS: Patients included in this study underwent staged CWUT surgeries with mastoid cortex plasty (MCP) for well-aerated ears (grade 3) and bony mastoid obliteration (BMO) for poorly aerated ears (grade 2-0). Of the 115 ears included in this study, 62 were followed for more than 5 years. Recurrence rates with deep retraction pocket formation were assessed using the Kaplan-Meier survival analysis. The aeration was graded as: 0, no aeration; 1, aeration of only the mesotympanum; 2, aeration of the entire tympanic cavity; and 3, aeration of both the tympanic and mastoid cavities. RESULTS: No recurrence was observed in ears associated with grade 3 aeration that underwent MCP or in ears with grade 2 aeration that underwent BMO during second-stage surgery. For grades 0 and 1 aeration ears, the recurrence rates were 8.1% after 5 years and 12.5% after 10 years (p < 0.05), and the aeration of recurrent ears deteriorated to grade 0. CONCLUSION: Aeration during second-stage surgery predicts the final outcome.

Surgical results of 29 ears with congenital middle ear anomalies; Microscopic vs. endoscopic ear surgery.

OBJECTIVE: Although congenital middle ear anomalies include various types of ossicular anomalies, all of these can be treated by ossiculoplasty or stapes surgery. Transcanal endoscopic ear surgery (TEES) is a minimally invasive surgical method for middle ear disease with an excellent surgical view that has been widely adopted worldwide. To determine the efficacy of TEES for middle ear anomalies, we describe the surgical results and compare the hearing outcomes between patients treated by TEES and microscopic ear surgery (MES). METHODS: A total of 39 ears with congenital middle ear anomalies were treated surgically at the University Hospital of Kochi Medical School between January 2011 and December 2021. In total, 29 ears of 23 patients were included in the study. Demographics, type of anomaly, surgical methods, pre- and postoperative hearing thresholds, and surgical complications were investigated by retrospective chart review. RESULTS: Of the 29 ears, 11 were treated by MES and 18 were treated by TEES. There were no differences in sex, age, preoperative hearing thresholds, or rate of stapes surgery between the two groups. The mean air-bone gap improvement was 20.6 dB in the MES group and 28.8 dB in the TEES group; these values were not significantly different. The median operation time was not significantly different between the MES and TEES groups (125 and 130 min, respectively). The improvements of air conduction in class 1 and 2 (stapes surgery) and class 3 (ossiculoplasty) cases were also not different between the groups. CONCLUSIONS: TEES achieved comparable hearing outcomes to MES without postauricular or endaural incisions. Further, class 1 and 2 anomalies demonstrated hearing improvement similar to class 3 without major complications. Since the surgical field limited around the ossicular chain, coupled with the fact that the middle ear anomaly itself does not exhibit inflammation leading to unfavorable bleeding, TEES is a feasible surgical procedure for all types of congenital ossicular anomalies.

Neuropsychiatric Systemic Lupus Erythematosus in a Patient with Pancytopenia and Chronic Schizophrenia Requiring Hospitalisation.

We herein report a patient with systemic lupus erythematosus (SLE) and neuropsychiatric SLE (NPSLE), who had been misdiagnosed with schizophrenia for a long time and presented with pancytopenia. Brain magnetic resonance imaging revealed sporadic punctate hyperintense areas in the cerebral white matter. Single-photon emission computed tomography revealed a clear decrease in blood flow from the parietotemporal association area to the temporal lobe. NPSLE is a serious organ complication that significantly worsens the SLE prognosis. NPSLE symptoms are diverse and difficult to diagnose and differentiate from those of other neuropsychiatric disorders, especially in an early onset.

Hypopituitarism due to CNS Aspergillus Infection.

A 59-year-old man was admitted to our hospital with hyponatremia. An endocrine examination indicated panhypopituitarism, and magnetic resonance imaging revealed a mass-like lesion in the pituitary gland. Sinus endoscopy revealed a fungal mass in the sphenoid sinus, and the patient was diagnosed with hypopituitarism due to aspergillosis of the central nervous system (CNS). The patient's hyponatremia resolved with hydrocortisone replacement. Although the right internal carotid artery was eventually occluded, antifungal medications were administered for the aspergillosis, and the patient's general condition improved. The patient's CNS lesions have remained under control since discharge. This is the first case to suggest that ACTH secretion may be relatively preserved in Aspergillus-induced hypopituitarism.

Math1, retinoic acid, and TNF-α synergistically promote the differentiation of mucous cells in mouse middle ear epithelial cells in vitro.

BACKGROUND: A key issue in otitis media (OM) is mucous cell metaplasia in the middle ear mucosa, a condition for hyperproduction of mucus in the middle ear mucosa and development of chronic OM. However, little is known about the driving force for the differentiation of mucous cells in OM. METHODS: Mouse middle ear epithelial cells (mMEECs) were used in this study to test whether Math1, a critical transcription factor for the development of mucous cells in the intestine, synergizes with inflammatory cytokines (tumor necrosis factor-α (TNF-α)) and other epithelial differentiation factors (retinoid acid (RA)) to induce the differentiation of mMEECs into mucus-like cells in vitro. Simultaneously, Math1 was transduced into the middle ear mucosa in order to observe whether it induces mucous cell hyperplasia in vivo. RESULTS: Math1 significantly increased the mucus cell numbers in the middle ear mucosa of mice. Math1, in the presence of TNF-α and epithelial differentiation factor RA, synergistically promoted the differentiation of mMEECs into mucus-like cells through upregulation of mucins and their chaperones: trefoil factors in vitro. RA treatment for 12 h activated Math1, although RA alone had very limited effects on mucus-like cell differentiation. CONCLUSION: Math1 plays a critical role in the pathogenesis of OM by induction of mucous cell differentiation in the presence of TNF-α and RA.

Extent of arterial tumor enhancement measured with preoperative MDCT gastrography is a prognostic factor in advanced gastric cancer after curative resection.

OBJECTIVE: The objective of this study was to investigate the correlation between pathologic findings and arterial tumor enhancement at MDCT gastrography of patients with a prognosis of advanced gastric cancer after curative resection. MATERIALS AND METHODS: The cases of 41 patients with advanced gastric cancer (23 men, 18 women; age range, 35-92 years; median, 60 years) who underwent MDCT gastrography and optical endoscopy before surgery were retrospectively evaluated. Two radiologists reviewed virtual endoscopic and multiplanar reconstruction images to measure arterial phase CT values of the inner tumor margin and healthy gastric wall. They used consensus regions of interest on a cross-sectional image of the largest tumor diameter and then calculated tumor-to-normal wall enhancement ratio (TNR). Advanced gastric cancers were divided into high- and low-TNR groups with mean TNR as the cutoff. The correlations between groups and pathologic factors, patient survival, and mode of recurrence were studied. RESULTS: Multivariate logistic regression analysis showed that the arterial tumor enhancement ratio correlated with both microvessel density and lymphatic vessel invasion. The survival rate after curative resection was worse for the high-TNR group than for the low-TNR group. The rate of lymphatic and hematogenous recurrences was also higher in the high-TNR group. Multivariate survival analysis revealed that TNR was an independent prognostic factor. CONCLUSION: The extent of arterial tumor enhancement correlated with tumor angiogenesis and lymphatic vessel invasion and was a useful prognostic indicator after curative resection in patients with advanced gastric cancer.

[Endoscopic ear surgery for traumatic ossicular disruptions].

Although endoscopic ear surgery (EES) has been used to perform middle ear surgery since 1993, it has not become as common in otologic surgery as it is in endoscopic sinus surgery. This report discusses the problems and the indications for EES in traumatic ossicular disruptions in two cases. Case 1 was a 33-year-old man with a left longitudinal temporal bone fracture who presented with mixed hearing loss, with an average hearing level of 45.0 dB in the left ear. He underwent EES, which revealed incudostapedial joint disrutption. Repositioning of the incus resulted in an improvement in hearing to 18.3 dB postoperatively. Case 2 was a 30-year-old man with a right mixed hearing loss of 56.7 dB. Computed tomography showed a right longitudinal temporal bone fracture and dislocation of the incus. EES revealed dislocation of the incus and fracture of the anterior crus of the stapes. A type IV tympanoplasty was performed, interpositioning the autologous incus between the footplate and the malleus handle. Postoperatively, the average hearing level was 18.3 dB, with a 1.7-dB air-bone gap. Traumatic ossicular disruptions are considered to be a good indication for EES.

Hypereosinophilic syndrome presenting as eosinophilic gastroenteritis exacerbated by clopidogrel bisulphate.

Clopidogrel is a widely prescribed prodrug with antithrombotic activity that functions by irreversibly inhibiting the P2Y12 receptors on platelets; nevertheless, drug-induced eosinophilia from this drug is rarely reported. An 81-year-old man was diagnosed with cerebral infarction 2 months earlier and was admitted to our hospital with rash, fever, wheezing, and stomach discomfort after being initiated with clopidogrel treatment. Based on his medical history, chest CT, and gastroscopy, we diagnosed him with clopidogrel-induced hypereosinophilic syndrome. After discontinuation of clopidogrel, the eosinophilia and symptoms improved. In cases of drug-induced eosinophilia, it is important to obtain a detailed medical history.

Denileukin diftitox-induced systemic capillary leak syndrome with acute kidney injury.

Systemic capillary leak syndrome is a rare and life-threatening disorder, characterized by recurrent episodes of unexplained hypotension, hemoconcentration, and hypoalbuminemia. This condition is caused by leakage of plasma and proteins into the extravascular space and can be classified as either idiopathic or secondary. Secondary systemic capillary leak syndrome can result from cancer, infections, medications, or surgery. Systemic capillary leak syndrome frequently develops as a side effect of denileukin diftitox treatment of refractory cutaneous T-cell lymphoma. However, the pathophysiology of this disease is not well understood. Herein, we report a case of denileukin diftitox-induced systemic capillary leak syndrome.

Changes during medical treatments before adenotonsillectomy in children with obstructive sleep apnea.

OBJECTIVES: The severity of pediatric obstructive sleep apnea (OSA) can vary from mild to very severe (AHI ≥ 30 events/h) with the seasons. The efficacy of medical treatment has been investigated in cases of mild and moderate pediatric OSA, but not in severe cases thoroughly. METHODS: Our prospective cohort study involved 205 children who visited our outpatient clinic between December 2014 and May 2020. We performed home sleep tests after the initial visit, and then polysomnography after optimizing the control of rhinitis, sinusitis, adenoid hypertrophy, and tonsillitis by using medical treatments. RESULTS: The respective proportions of patients who improved to obstructive AHI (O-AHI) < 1/h or who proceeded to surgery were 43.4% and 62.3% in mild cases; 43.3% and 52.2% in moderate cases; 30.2% and 68.4% in severe cases; and 0.0% and 100% in very severe cases. Additionally, nadir SaO2 improved significantly between before and after medical treatment in both O-AHI < 1/h and O-AHI ≥ 1/h patients (respectively p < 0.0001, p = 0.0009). The lowest nadir SaO2 before medical treatment was 74% in patients in whom O-AHI was normalized after medical treatments. CONCLUSION: Medical treatment instituted before a surgical decision is made can provide substantial benefits and avoid unnecessary surgery if there is time for such treatments. In contrast, it may be difficult to normalize the O-AHI in pediatric patients with very severe OSA or a nadir SaO2 of less than 74% by medical treatment.