Effect of Antimicrobial Prophylaxis Duration on Health Care-Associated Infections After Clean Orthopedic Surgery: A Cluster Randomized Trial.

Importance: Postoperative health care-associated infections are associated with a greater deterioration in patients' general health status and social and economic burden, with at least 1 occurring in approximately 4% of acute care hospital patients. Antimicrobial prophylaxis prevents surgical site infections in various orthopedic procedures; however, its relationship with health care-associated infections remains unknown. Objective: To examine whether a shorter antimicrobial prophylaxis duration of less than 24 hours after surgery is not inferior to a longer duration in preventing health care-associated infections after clean orthopedic surgery. Design, Setting, and Participants: This open-label, multicenter, cluster randomized, noninferiority clinical trial was conducted in 5 tertiary referral hospitals in greater Tokyo metropolitan area, Japan, from May to December 2018. Adult patients undergoing clean orthopedic surgery were recruited until the planned number of participants was achieved (500 participants per group). Statistical analysis was conducted from July to December 2019. Interventions: Antimicrobial prophylaxis was discontinued within 24 hours after surgery in group 24 and 24 to 48 hours after surgery in group 48. Group allocation was switched every 2 or 4 months according to the facility-based cluster rule. Study-group assignments were masked from participants. Main Outcomes and Measures: The primary outcome was the incidence of health care-associated infections requiring antibiotic therapies within 30 days after surgery. The noninferiority margin was 4%. Results: Of the 1211 participants who underwent cluster allocation, 633 participants were in group 24 (median [IQR] age, 73 [61-80] years; 250 men [39.5%] and 383 women [60.5%]), 578 participants were in group 48 (median [IQR] age, 74 [62-81] years; 204 men [35.3%] and 374 women [64.7%]), and all were eligible for the intention-to-treat analyses. Health care-associated infections occurred in 29 patients (4.6%) in group 24 and 38 patients (6.6%) in group 48. Intention-to-treat analyses showed a risk difference of -1.99 percentage points (95% CI, -5.05 to 1.06 percentage points; P < .001 for noninferiority) between groups, indicating noninferiority. Results of adjusted intention-to-treat, per-protocol, and per designated procedure population analyses supported this result, without a risk of antibiotic resistance and prolonged hospitalization. Conclusions and Relevance: This cluster randomized trial found noninferiority of a shorter antimicrobial prophylaxis duration in preventing health care-associated infections without an increase in antibiotic resistance risk. These findings lend support to the global movement against antimicrobial resistance and provide additional information on adequate antimicrobial prophylaxis for clean orthopedic surgery. Trial Registration: Identifier: UMIN000030929.

[RISK FACTORS FOR INFECTIONS AT SURGICAL SITES AND REMOTE REGIONS IN PATIENTS UNDERGOING LAPAROSCOPIC PYELOPLASTY AND EVALUATION OF ANTIMICROBIAL PROPHYLAXIS].

(Objectives) We measured the incidences of surgical site infections (SSIs) and remote infections (RIs) in patients undergoing laparoscopic pyeloplasty to treat ureteropelvic junction obstruction, and the effects of prophylactic antimicrobial agents. (Patients and Methods) We compared the incidences of SSI and RI, risk factors for such infections, and differences in the prophylactic antimicrobial protocols in 94 patients who underwent laparoscopic pyeloplasty at our hospital from August 2009 to June 2021. (Results) Two patients experienced SSIs (2.1%) and three had RIs (3.2%). There were no significant differences in the incidence of either infection type in those who complied and did not comply with the prophylactic antimicrobial guidelines. (Conclusions) Laparoscopic pyeloplasty is associated with low incidences of both SSI and RI; prophylactic antimicrobials may not be required. A large multicenter survey is required for continuous evaluation of SSIs and RIs and to accumulate data.

Regional differences in the incidence of asthma exacerbations in Japan: A heat map analysis of healthcare insurance claims data.

BACKGROUND: In Japan, regional differences in asthma mortality have been reported; however, regional differences in asthma exacerbations have not been studied extensively. Therefore, using a health insurance claims database, we investigated the regional differences in the incidence of asthma exacerbations in Japan. METHODS: This study used data from Medi-Scope (Japan Medical Information Research Institute Inc., Japan)-a nationwide health insurance claims database. Patients with asthma at the index date (the latest date of an asthma-related prescription with an asthma diagnosis before October 1, 2018) were included in the analysis. The pre-index period was defined as 1 year before the index date, and the follow-up period as 1 year after the index date. The incidence of asthma exacerbation events was analyzed for each region. RESULTS: The primary analysis population comprised 24,883 patients who were continuously prescribed ICS or ICS/LABA at least four times during the pre-index period. The incidence rate of asthma exacerbations with hospitalization was the highest in Chugoku (2.95/100 person-years [95% CI, 1.97-4.43]) and the lowest in Kanto (1.52/100 person-years [95% CI, 1.26-1.83]). The incidence rate of asthma exacerbations for the composite outcome of hospitalization, injectable corticosteroid prescription, and oral corticosteroid burst was the highest in Fukui (105.00/100 person-years [95% CI, 64.53-170.85]) and the lowest in Nagasaki (15.69/100 person-years [95% CI, 10.84-22.72]). CONCLUSIONS: Regional differences in the incidence of asthma exacerbations as well as their treatments were observed in Japan.

[IPSILATERAL SYNCHRONOUS FUMARATE HYDRATASE-DEFICIENT RENAL CELL CARCINOMA AND MULTILOCULAR CYSTIC RENAL NEOPLASM OF LOW MALIGNANT POTENTIAL: A CASE REPORT AND LITERATURE REVIEW].

A 75-year-old man was being followed up at a nearby clinic for hypertension and chronic renal failure. The patient was referred to our department as abdominal ultrasound revealed a left renal tumor. Plain computed tomography (CT) showed a 50 mm complex renal cyst in the upper pole of the left kidney. Plain magnetic resonance imaging showed a cystic mass with numerous septa. Partial thickening of the septa was suspected, and the lesion was classified as Bosniak IIF or III. As the patient had renal dysfunction, regular imaging study of the tumor lesion was performed to determine the timing of surgery. In the following year, plain CT revealed a new renal tumor 20 mm in diameter located lateral to the known tumor, with the mass having a tendency to increase. The patient underwent a laparoscopic radical left nephrectomy after the introduction of hemodialysis. Histopathological examination revealed that the tumor located in the medial upper pole of the left kidney was a multilocular cystic renal neoplasm of low malignant potential and that the new tumor located lateral to the known tumor was fumarate hydratase-deficient renal cell carcinoma. Simultaneous occurrence of fumarate hydratase-deficient renal cell carcinoma and multilocular cystic renal neoplasm of low malignant potential in the ipsilateral kidney is extremely rare. We report our case with a review of the literature.

A sliding scale to predict postoperative complications undergoing posterior spine surgery.

BACKGROUND: There is a lack of consensus of operative time (OT) and estimated blood loss (EBL) for elderly patients based on the predicted risk of complications after posterior spine surgery. The purpose of this study was to evaluate the effect of age, OT, and EBL on the postoperative complication risk and to develop a simple sliding scale. METHODS: We explored prospectively collected data of consecutive patients who underwent posterior spine surgery in seven tertiary referral hospitals from November 2013 to May 2016. Age (<70, 70-74, 75-79, 80-84, ≥85 years), OT (<2, 2-<3, 3-<4, 4-<5, ≥5 h), and EBL (<500, 500-<1000, 1000-<1500, 1500-<2000, ≥2000 ml) were categorized ranging from 1 (lowest) to 5 (highest). The association between the crude cumulative categories' number and the incidence of complications was analyzed. We further evaluated the association by re-categorizing the cumulative number into three groups (3-4, 5-10, ≥11). RESULTS: Total of 2416 patients (median age: 70 years old) were enrolled and major complications were observed in 75 (3.1%) patients. Age, OT, and EBL showed similar odds ratio (1.18-1.19) as each category increased. The cumulative categories' number fitted the estimate complication risk (Hosmer-Lemeshow P = 0.87), and statistically significant trend was observed between predicted and actual complication rates (Cochran-Armitage test, P < 0.001). When cumulative categories' numbers were stratified into three groups, significant increasing trend of risk were observed (Mantel-Haenszel P < 0.001). Based on the categorical numbers, we proposed a simple sliding scale. CONCLUSION: Our data indicated that the risk of postoperative complication was associated with cumulative score based on increased age, OT, and EBL. A simple sliding scale was developed based on these factors, which may be useful to predict complication risk after posterior spine surgery.

Association Between Normothermia at the End of Surgery and Postoperative Complications Following Orthopedic Surgery.

BACKGROUND: Maintaining perioperative normothermia is recommended by recent guidelines for the prevention of surgical site infections (SSIs). However, the majority of supporting data originates outside the field of orthopaedic surgery. METHODS: The effect of normothermia was explored using the prospectively collected data of consecutive patients who underwent single-site surgery in 7 tertiary referral hospitals between November 2013 and July 2016. SSIs, urinary tract infections (UTIs), respiratory tract infections (RTIs), cardiac and cerebral events (CCE), and all-cause mortality rates within 30 days after surgery were compared between patients with normothermia (body temperature ≥36°C) and those with hypothermia (<36°C) at the end of surgery, after closure. Multivariable adjusted and inverse-probability weighted regression analyses were performed. RESULTS: The final cohort included 8841 patients. Of these, 11.4% (n = 1008) were hypothermic. More than 96% were evaluated in person by the physicians. After adjusting for multiple covariates, normothermia was not significantly associated with SSIs (adjusted odds ratio [aOR] 1.18, 95% confidence interval [CI] 0.59-2.33), UTIs (aOR 1.14, 95% CI 0.66-1.95), RTIs (aOR 0.60, 95% CI 0.31-1.19), or CCE (aOR 0.53, 95% CI 0.26-1.09). In contrast, normothermia was associated with a lower risk of 30-day mortality (aOR 0.26, 95% CI 0.11-0.64; P < .01; weighted hazard ratio 0.21, 95% CI 0.07-0.68; P = .002). In a subgroup analysis, normothermia was associated with reduced mortality in all types of surgical procedures. CONCLUSIONS: Whereas our findings suggest no clear association with SSI risks following orthopedic surgery, our study supports maintaining perioperative normothermia, as it is associated with reduced 30-day mortality.

Non-inferior comparative study comparing one or two day antimicrobial prophylaxis after clean orthopaedic surgery (NOCOTA study): a study protocol for a cluster pseudo-randomized controlled trial comparing duration of antibiotic prophylaxis.

BACKGROUND: Antimicrobial prophylaxis (AMP) is one of the most important measures for preventing surgical site infections (SSIs); however, controversies remain regarding its adequate duration. Although the World Health Organization and the Center for Disease Control and Prevention do not recommend additional AMP after closure, the American Society of Health-System Pharmacists and the Musculoskeletal Infection Society permit the use of postoperative AMP, but recommend discontinuation within 24 h. Similarly, the Japanese Society of Chemotherapy and the Japan Society for Surgical Infection also permit AMP within 24-48 h after various orthopaedic procedures. In these guidelines, recommendations regarding AMP duration were weak due to a relative lack of evidence, and currently, there is no high-quality evidence comparing AMP use within 24 h versus 24-48 h regarding orthopaedic procedures. Urinary tract infection (UTI) and respiratory tract infection (RTI) are also important health care-associated infections (HAIs) faced after surgery. Although AMP duration may affect these HAIs, its effects have not been well evaluated. METHODS: We have organized a multicenter, prospective, cluster pseudo-randomized controlled trial to examine the non-inferiority of shorter AMP duration (within 24 h) against longer duration (24-48 h) in preventing postoperative HAIs. Participating facilities will be divided into two groups. In Group 24, AMP will be discontinued within 24 h after surgery. In Group 48, AMP will be discontinued within 24-48 h after surgery. The group allocation will be switched every 2 months until the targeted recruitment (500 participants per group) is met. The primary outcome will be the cumulative incidence of all HAIs (SSI, UTI, RTI, and other infectious diseases), which require antibiotic therapies within 30 days after surgery. In addition to mortality and cardiovascular events, prolonged hospitalization (> 30 days) and the rate of antibiotic resistance rate of SSI pathogens will also be evaluated. Outcomes will be evaluated within 30-180 days after surgery in person by the surgeon, by mail, or by telephone survey. Data will be analyzed by a statistician not engaged in data collection. DISCUSSION: This study may provide valuable information for developing future recommendations for adequate AMP duration after clean orthopaedic surgery. TRIAL REGISTRATION: UMIN000030929, registered January 22, 2018.

Association between high fear-avoidance beliefs about physical activity and chronic disabling low back pain in nurses in Japan.

BACKGROUND: High prevalence of low back pain (LBP) in nurses has been reported globally. Ergonomic factors and work-related psychosocial factors have been focused on as risk factors. However, evidence on the role of fear-avoidance beliefs (FABs) concerning LBP in nurses is lacking. This study examined LBP prevalence and the association between FABs and chronic disabling LBP that interfered with work and lasted ≥ 3 months. METHODS: Female nurses (N = 3066; mean age = 35.8 ± 10.6 years) from 12 hospitals in Japan participated. A self-reported questionnaire was used to collect information on sociodemographics, LBP, work-related factors, and psychological distress. FABs about physical activity were assessed using a subscale from the FAB Questionnaire (score range = 0-24). The participants were asked to choose one of four statements regarding their LBP in the past 4 weeks: 1) I did not have LBP, 2) I had LBP without work difficulty, 3) I had LBP with work difficulty but without requiring absence from work, and 4) I had LBP requiring absence from work. If the participant had LBP in the past 4 weeks, it was also inquired if the LBP had lasted for ≥ 3 months. Chronic disabling LBP was defined as experiencing LBP with work difficulty in the past 4 weeks which had lasted for ≥ 3 months. In the nurses who had experienced any LBP in the past 4 weeks, we examined the association between FABs and experiencing chronic disabling LBP using multiple logistic regression models adjusting for pain intensity, age, body mass index, smoking status, psychological distress, hospital department, weekly work hours, night shift work, and the12 hospitals where the participants worked. RESULTS: Four-week and one-year LBP prevalence were 58.7 and 75.9%, respectively. High FABs (≥ 15) were associated with chronic disabling LBP (adjusted odds ratio = 1.76, 95% confidence interval [1.21-2.57], p = 0.003). CONCLUSIONS: LBP is common among nurses in Japan. FABs about physical activity might be a potential target for LBP management in nurses. TRIAL REGISTRATION: UMIN-CTR UMIN000018087. Registered: June 25, 2015.

Combination chemotherapy with gemcitabine and nab-paclitaxel for a metastatic pancreatic ductal adenocarcinoma patient undergoing hemodialysis.

In cancer patients, impairment of kidney function is not uncommon. Recently, the efficacy of the combination of gemcitabine and nab-paclitaxel for pancreatic ductal adenocarcinoma (PDAC) patients has been reported, however, there is no recommendation for dose and administration to patients undergoing hemodialysis (HD). A 66-year-old man began receiving HD for chronic renal failure 4 years previously. He suffered from diarrhea, back pain, and loss of appetite, and his weight gradually decreased. Abdominal dynamic computed tomography showed a 45-mm hypodense mass in the pancreatic body and a 30-mm hypodense mass in the liver. The patient was diagnosed with metastatic PDAC. He started combination chemotherapy of gemcitabine and nab-paclitaxel without dose modification. He developed pneumonia and neutropenia in the first and second courses, so we modified to a 60% dose of gemcitabine and nab-paclitaxel on day 1 every 2 weeks. After dose modification, he continued combination chemotherapy for over 7 months without severe adverse events or tumor progression. Combination chemotherapy using gemcitabine and nab-paclitaxel was effective in a PDAC patient undergoing HD. While it is possible to originally administer these drugs with no dose modification, early dose modification was needed for our patient because of severe adverse events.

[Clinical Outcomes of Palliative Radiation Therapy for Gastric Cancer Bleeding].

Only a few studies have been conducted regarding the palliative radiation therapy(RT)for gastric cancer(GC)bleeding. Data of 9 patients with gastric cancer requiring blood transfusions due to gastric bleeding who were treated with RT were reviewed. All patients were men with a median age of 83(range, 70-91)years. The clinical stage was ⅡB in 2 patients, Ⅲin 1, ⅣA in 1, and ⅣB in 5. Performing gastrectomy was difficult in 4 patients with distant metastasis or tumor invasion to adjacent organ, 3 with poor performance status, and 2 with advanced age. The median hemoglobin levels before RT was 6.0 (range, 3.3-7.7)g/dL, and all patients received blood transfusions before RT. Seven patients received 30 Gy RT and 2 patients received 50 Gy. Two patients received concurrent chemotherapy. A total of 2 hematological and 4 non-hematological treatment-related adverse events occurred. All patients improved conservatively. Hemorrhage occurred in 8 patients, except for 1. Of the 8 patients who responded to RT, 1 had rebleeding on day 81. The median rebleeding-free survival time from the beginning of RT was 125(range, 21-421)days. Palliative radiation therapy was useful for bleeding control in nonresectable gastric cancer.

The effect of the 'One Stretch' exercise on the improvement of low back pain in Japanese nurses: A large-scale, randomized, controlled trial.

Objectives: To evaluate the 'One Stretch' exercise's effect on improvements in low back pain (LBP), psychological factors, and fear avoidance in a large number of nurses. Methods: Between July 2015 and June 2016, we performed a prospective, randomized, parallel-group, multi-center study with central evaluations. Eligible patients were randomly assigned (1:1:1 ratio) to either the control group (Group A) or an intervention group (Group B: 30-min seminar about the 'One Stretch' exercise, Group C: B + physical and psychological approaches to LBP treatment). The primary outcome was subjective improvement from baseline to 6 months (improved/unchanged/worsened) and overall exercise habits (good/poor). Results: There were 4767 participants: 1799, 1430, and 1548 in Groups A, B, and C, respectively. We collected data on 3439 participants (949, 706, and 751 in Groups A, B, and C, respectively) at the 6-month follow-up. The improvement rates in Groups A, B, and C were 13.3%, 23.5%, and 22.6%, respectively. The worsened pain rates were 13.0%, 9.6%, and 8.1%, which decreased as the intervention degree increased (the Cochran-Armitage trend test: p < .0001). In Groups A, B, and C, 15.6%, 64.9%, 48.8% of the patients, respectively, exhibited exercise habits. Conclusion: The 'One Stretch' exercise is useful for improving LBP.

Evidence-based Care Bundles for Preventing Surgical Site Infections in Spinal Instrumentation Surgery.

STUDY DESIGN: A retrospective study, using prospectively collected data. OBJECTIVE: The aim of this study was to evaluate the impact of evidence-based care bundles for preventing surgical site infections (SSIs) in spinal instrumentation surgery. SUMMARY OF BACKGROUND DATA: About half of all SSIs are preventable via evidence-based methods. For successful SSI prevention, the bacterial load must be minimized, and methicillin-resistant Staphylococcus aureus (MRSA) protection must be maximized. However, it is difficult to cover all of these requirements by single preventative method. METHODS: We screened consecutive patients scheduled for spinal instrumentation surgeries at a single tertiary referral hospital for high surgical, SSI, and MRSA colonization risks. Evidence-based care bundles were implemented for high-risk patients and included 1) additional vancomycin prophylaxis, 2) diluted povidone-iodine irrigation, and 3) nasal and body decontamination. Patient demographics, comorbidities, operative features, and SSIs reported to the Japanese Nosocomial Infections Surveillance system were prospectively obtained in the same method by the same assessor and were used for the analyses. The results were compared before and after the application of the bundle. RESULTS: There were 1042 spinal instrumentation surgeries (741 before and 301 after care bundles) performed from November 2010 to December 2015. Of 301 surgeries, 57 cases (18.9%) received care bundles. There were no significant differences in patient backgrounds before and after the intervention. The SSI rate decreased significantly from 3.8% to 0.7% (P < 0.01) after the intervention, with an overall 82% relative risk reduction. A significant protective effect was observed in the multivariate analysis (adjusted odds ratio 0.18, 95% confidence interval: 0.04-0.77, P = 0.02). There were no MRSA-related SSIs among those that received care bundles, even though MRSA was the predominant pathogen in the study population. CONCLUSION: Evidence-based care bundles, applied in selected high-risk spinal instrumentation cases, minimized bacterial load, maximized MRSA protection, and significantly reduced SSI rates without topical vancomycin powder. LEVEL OF EVIDENCE: 4.

Gastrocnemius Myalgia as a Rare Initial Manifestation of Crohn's Disease.

The initial symptoms of Crohn's disease (CD) sometimes present as extraintestinal lesions, which can be a diagnostic challenge for physicians. Painful legs, known as "gastrocnemius myalgia syndrome", are rare complications that often precede abdominal manifestations. We herein report the case of a 38-year-old man who presented with bilateral leg myalgia lasting for 4 months. Magnetic resonance imaging showed abnormal intensity, and a muscle biopsy revealed inflammatory cell infiltration. Abdominal symptoms appeared three months after the myalgia onset, and the diagnosis of CD was confirmed later by endoscopic and radiological findings. To our knowledge, this is the first description of gastrocnemius myalgia syndrome in Japan.

The associations between magnetic resonance imaging findings and low back pain: A 10-year longitudinal analysis.

PURPOSE: To conduct a 10-year longitudinal analysis of the relationship between magnetic resonance imaging (MRI) findings and low back pain (LBP). MATERIALS AND METHODS: Ninety-one volunteers with a history of LBP, but without current LBP were recruited between 2005 and 2006. Participants' baseline demographics and MRI findings were recorded. All volunteers were invited for a follow-up MRI in 2016; of these, 49 volunteers (53.8%) participated in the follow-up. We enquired whether they had LBP history during the 10 years between the baseline and follow-up examinations. Sagittal T1 and T2-weighted MRI were used to assess the intervertebral space from T12/L1 to L5/S1. We evaluated the presence of disc degeneration by Pfirrmann's grading system, disc bulging, high intensity zone (HIZ), spondylolisthesis, and any type of Modic changes in the follow-up MRIs. We compared the follow-up MRI findings with the baseline findings; the progress of each finding over the 10 years were also compared between the groups with (n = 36) and without (n = 13) LBP. RESULTS: Average age of the study participants at follow-up was 44.8 years; 25 were female and 24 were male. Average age, sex, body mass index, and smoking habits of those who did and did not participate in the follow-up study, as well as the demographic characteristics of those who did and did not have LBP history during the 10 years, were not significantly different. Compared with the group without LBP history, the group that had LBP history during the 10 years did not have a significantly increased prevalence of disc degeneration, disc bulging, and HIZ in the follow-up and baseline MRIs. Spondylolisthesis and any type of Modic changes were also not associated with LBP history during the 10 years. CONCLUSIONS: Follow-up MRI findings consistent with Pfirrmann grading ≥4, disc bulging, HIZ, spondylolisthesis, and any type of Modic changes were not associated with LBP history during the 10 years between the baseline and follow-up study. The progresses of these findings were also not associated with the LBP history. In addition, baseline MRI findings were not associated with LBP history during the 10 years; therefore, our data suggest that baseline MRI findings cannot predict future LBP.

The Superiority of Vonoprazan-based First-line Triple Therapy with Clarithromycin: A Prospective Multi-center Cohort Study on Helicobacter pylori Eradication.

Objective We evaluated the safety and efficacy of vonoprazan-based amoxicillin and clarithromycin 7-day triple therapy (VAC) in comparison to proton pump inhibitor (PPI)-based (PAC) as a first-line treatment and vonoprazan-based amoxicillin and metronidazole 7-day triple therapy (VAM) in comparison to PPI-based (PAM) as a second-line treatment for the eradication of Helicobacter pylori in Japan. Methods We performed a non-randomized, multi-center, parallel-group study to compare first-line VAC to PAC and second-line VAM to PAM. A pre-planned subgroup analysis on CAM resistance was also performed. Safety was evaluated with an adverse effects questionnaire (AEQ), which was completed by patients during therapy. Results The first-line eradication rates (ER) in the intention-to-treat (ITT) and per protocol (PP) analyses were 84.9% (95% CI: 81.9-87.6%, n=623) and 86.4% (83.5-89.1%, n=612), respectively, for VAC and 78.8% (75.3-82.0%, n=608) and 79.4% (76.0-82.6%, n=603), respectively, for PAC. The ER of VAC was higher than that of PAC in the ITT (p=0.0061) and PP analyses (p=0.0013). The ERs for VAC in patients with CAM-resistant and CAM-susceptible bacteria were 73.2% (59.7-84.2%, n=56) and 88.9% (83.4-93.1%, n=180), respectively. PAC was associated with higher AEQ scores for diarrhea, nausea, headache, and general malaise. In the second-line ITT and PP analyses VAM achieved ERs of 80.5% (74.6-85.6%, n=216) and 82.4% (76.6-87.3%, n=211), respectively, while PAM achieved ERs of 81.5% (74.2-87.4%, n=146) and 82.1% (74.8-87.9%, n=145), respectively. No significant differences were observed in the ITT (p=0.89) or PP (p=1.0) analyses. Conclusion The ER of first-line VAC was higher than that of PAC, but still <90%. No difference was observed between second-line VAM and PAM. Vonoprazan-based triple therapy was safe and well tolerated.

The relationship between findings on magnetic resonance imaging and previous history of low back pain.

The objective of this study was to evaluate the relationship between magnetic resonance imaging (MRI) findings and previous low back pain (LBP) in participants without current LBP. Current LBP was defined as LBP during the past month. Previous LBP was defined as a history of medical consultation for LBP. Ninety-one participants without current LBP were included. Sagittal T2-weighted MRI was used to assess the intervertebral space from T12/L1 to L5/S1. These images were classified into five grades based on the Pfirrmann grading system. Furthermore, we evaluated the presence of disk bulging, high-intensity zone, and spondylolisthesis. We compared the MRI findings between groups with (27 participants) and without (64 participants) previous LBP without current LBP. Intraobserver and interobserver kappa values were evaluated. Participants had an average age of 34.9 years; 47 were female and 44 were male; and their average body mass index was 21.8 kg/m2. Compared to the group of participants without previous LBP, the group of participants with previous LBP had a significantly higher incidence of disk degeneration such as a Pfirrmann grade ≥3, disk bulging, and high-intensity zone in the analyses adjusted by age and sex. There were no significant differences in spondylolisthesis between the groups. An odds ratio of >10 was only found for Pfirrmann grade ≥3, ie, a Pfirrmann grade ≥3 was strongly associated with a history of previous LBP in participants without current LBP.

Leg Lengthening as a Means of Improving Ambulation Following an Internal Hemipelvectomy.

Reconstructive surgery following an internal hemipelvectomy for a malignant pelvic tumor is difficult due to the structural complexity of the pelvis and the massive extension of the tumor. While high complication rates have been encountered in various types of reconstructive surgery, resection without reconstruction reportedly involved fewer complications. However, this method often results in limb shortening with resultant instability during walking. We reported herein leg lengthening performed to correct lower limb shortening after an internal hemipelvectomy, which improved ambulatory stability and overall QOL. An 18-year-old male patient came to our hospital to correct a lower limb discrepancy resulting from a left internal hemipelvectomy. His left pelvis and proximal femur had been resected, and the femur remained without an acetabular roof. His left lower limb was about 8 centimeters shorter. The left tibia was lengthened 8 centimeters with an external fixator. After the lengthening, the patient was able to walk without support and his gait remarkably improved. Additionally he no longer required placing a wallet in his back pocket as a pad as a means of raising the left side of his torso while sitting. Leg lengthening was a useful method of improving ambulation after an internal hemipelvectomy.

A population approach to analyze the effectiveness of a back extension exercise "One Stretch" in patients with low back pain: A replication study.

BACKGROUND: We examined the effectiveness of an intervention using a standing back extension exercise called "One Stretch", based on the McKenzie method, in improving or preventing low back pain and disability in Japanese care workers. METHODS: We conducted a non-randomized controlled trial in Japan. Care workers in the intervention group received an exercise manual and a 30-minute seminar on low back pain and were encouraged to exercise in groups, while care workers in a control group were given only the manual. All care workers answered questionnaires at baseline and after one year on the subjective improvement in low back pain, whether they had had a medical consultation for low back pain, and the exercise compliance. Low back pain with disability was assessed by the Oswestry Disability Index. RESULTS: Participants included 89 workers in the intervention group and 78 in the control group. Background characteristics did not differ significantly between the two groups. Compared to the control group, a greater number of care workers in the intervention group showed improvements in low back pain or prevented it, did not have a medical consultation for low back pain, and exercised regularly. Furthermore, significantly fewer care workers in the intervention group suffered from low back pain with disability by the end of the study period than in the control group. CONCLUSION: The population approach about the exercise "One Stretch" led to better compliance with the exercise, and was effective for improving or preventing low back pain and in decreasing the likelihood of having a medical consultation for low back pain.

Diffuse fatty metamorphosis of a large, well-differentiated hepatocellular carcinoma originating in the normal liver: a case report and literature review.

Fatty changes are frequently observed in small, well-differentiated hepatocellular carcinomas (HCCs), but are rarely observed in large (over 30 mm in diameter) lesions. Here, we report a 76-year-old man who developed a large (58 mm in diameter), well-differentiated HCC with diffuse extensive fatty changes in the right lobe of the liver. He had no history of alcohol abuse, obesity, or hepatitis B or C infection, and no autoantibodies, but he did have type 2 diabetes. The serum alpha-fetoprotein level was within the normal range, and ultrasonography showed a round hyperechoic lesion. Dynamic contrast-enhanced computed tomography revealed a tumor with inhomogeneous low attenuation in the arterial, portal, and venous phases, mimicking an angiomyolipoma. The patient underwent central bisegmentectomy of the liver, and the histological diagnosis was well-differentiated HCC with diffuse extensive fatty changes. The surrounding non-cancerous area was normal. A review of the published literature found six published cases of large, well-differentiated HCC with extensive fatty changes. Unlike the patients in most previous reports, our patient did not have any underlying liver disease and had no history of alcohol abuse.

Risk Factors for Prolonged Treatment of Whiplash-Associated Disorders.

OBJECTIVES: Whiplash-associated disorders (WAD) are the most common injuries that are associated with car collisions in Japan and many Western countries. However, there is no clear evidence regarding the potential risk factors for poor recovery from WAD. Therefore, we used an online survey of the Japanese population to examine the association between potential risk factors and the persistence of symptoms in individuals with WAD. MATERIALS AND METHODS: An online survey was completed by 127,956 participants, including 4,164 participants who had been involved in a traffic collision. A random sample of the collision participants (n = 1,698) were provided with a secondary questionnaire. From among the 974 (57.4%) respondents to the secondary questionnaire, we selected 183 cases (intractable neck pain that was treated over a period of 6 months) and 333 controls (minor neck pain that was treated within 3 months). Multivariable logistic regression analysis was used to evaluate the potential risk factors for prolonged treatment of WAD. RESULTS: Female sex, the severity of the collision, poor expectations of recovery, victim mentality, dizziness, numbness or pain in the arms, and lower back pain were associated with a poor recovery from WAD. CONCLUSIONS: In the present study, the baseline symptoms (dizziness, numbness or pain in the arms, and lower back pain) had the strongest associations with prolonged treatment for WAD, although the psychological and behavioral factors were also important. These risk factors should be considered when evaluating patients who may have the potential for poor outcomes.