Costs of integrating hepatitis B screening and antiviral prophylaxis into routine antenatal care in Burkina Faso: Treat all versus targeted strategies.

OBJECTIVE: Economic feasibility of eliminating mother-to-child transmission (MTCT) of hepatitis B virus (HBV) in highly endemic African countries remains uncertain. Prevention of MTCT (PMTCT) involves screening pregnant women for hepatitis B surface antigen (HBsAg), identifying those with high viral loads or hepatitis B e antigen (HBeAg), and administering tenofovir prophylaxis to high-risk women. We estimated the costs of integrating PMTCT services into antenatal care in Burkina Faso, based on four different strategies to select women for tenofovir prophylaxis: (1) HBV DNA (≥200 000 IU/mL), (2) HBeAg, (3) hepatitis B core-related antigen rapid diagnostic test (HBcrAg-RDT) and (4) all HBsAg-positive women. METHODS: Using a micro-costing approach, we estimated the incremental economic cost of integrating each strategy into routine antenatal care in 2024, compared to neonatal vaccination alone. Sensitivity analyses explored variations in prevalence, service coverage, test and tenofovir prices. RESULTS: HBcrAg-RDT strategy was the least expensive, with a total economic cost of US$3959689, compared to HBV DNA (US$6128875), HBeAg (US$4135233), and treat-all (US$4141206). The cost per pregnant woman receiving tenofovir prophylaxis varied from US$61.88 (Treat-all) to US$1071.05 (HBV DNA). The Treat-All strategy had the lowest marginal cost due to a higher number of women on tenofovir (66928) compared to HBV DNA (5722), HBeAg (10020), and HBcrAg-RDT (7234). In sensitivity analyses, the treat-all strategy became less expensive when the tenofovir price decreased. CONCLUSION: HBcrAg-RDT minimizes resource use and costs, representing 0.61% of Burkina Faso's 2022 health budget. This study highlights the potential economic feasibility of these strategies and provides valuable resources for conducting cost-effectiveness analyses.

Association between postoperative fall history and toe grip strength in patients after total knee arthroplasty: A prospective observational study.

BACKGROUND: Factors associated with falls after total knee arthroplasty (TKA) have been rarely reported. The aim of this study was to identify factors that influence the incidence of falls after TKA, focusing on toe grip strength (TGS) in particular, which has been associated with falls in older adults. METHODS: 217 patients who underwent TKA were included and followed up for 1 year. Main study outcome measures were the presence or absence of falls within 1 year after TKA. Multiple logistic regression analysis was used with postoperative falls as the dependent variable and preoperative falls and postoperative TGS on the affected sides as independent variables. RESULTS: 170 (43 and 127 in the fall and non-fall groups) patients were included in the analysis. The presence of a preoperative falls history before TKA and a weak postoperative affected TGS indicated an increased susceptibility of the patient to fall postoperatively. CONCLUSIONS: Results of the current study revealed the association between postoperative TGS and postoperative falls. We highlight the importance of preoperative fall monitoring and postoperative TGS evaluation to prevent falls after TKA.

Efficacy of antiviral therapy for the prevention of mother-to-child transmission of hepatitis B virus and the risk of postpartum hepatitis flare after discontinuation of antiviral therapy.

The use of nucleos(t)ide analogs (NAs) is recommended for mothers with a high viral load of hepatitis B virus (HBV) during the second or third trimester of pregnancy. However, postpartum hepatitis flares can occur in some cases. We examined the efficacy of NA administration for the prevention of mother-to-child transmission of hepatitis B virus, and evaluated the risk of postpartum hepatitis flares in mothers after NA discontinuation. Nine pregnant women with a high viral load (HBV DNA ≥5.3 log IU/mL) received tenofovir disoproxil fumarate (TDF) at approximately 28 weeks of gestation, and TDF was discontinued at 4-10 weeks after delivery. We evaluated the virological and biochemical parameters in mothers after TDF discontinuation. Hepatitis flares in mothers were defined as alanine transaminase level ≥60 U/L. None of the infants developed any congenital anomaly or acquired HBV infection during infancy. Hepatitis flares occurred within 6 months after TDF discontinuation in five of seven cases, whereas two cases were lost to follow-up. Furthermore, three cases required the resumption of NA use. NA administration was highly effective against mother-to-child-transmission of HBV in pregnant women with high HBV DNA levels. However, hepatitis flares were commonly observed after NA discontinuation in the postpartum period. Patients should be followed up carefully after NA discontinuation, and NA resumption should be considered based on a comprehensive assessment of virological and biochemical parameters.

Multiscale modeling of HBV infection integrating intra- and intercellular viral propagation to analyze extracellular viral markers.

Chronic infection with hepatitis B virus (HBV) is caused by the persistence of closed circular DNA (cccDNA) in the nucleus of infected hepatocytes. Despite available therapeutic anti-HBV agents, eliminating the cccDNA remains challenging. Thus, quantifying and understanding the dynamics of cccDNA are essential for developing effective treatment strategies and new drugs. However, such study requires repeated liver biopsy to measure the intrahepatic cccDNA, which is basically not accepted because liver biopsy is potentially morbid and not common during hepatitis B treatment. We here aimed to develop a noninvasive method for quantifying cccDNA in the liver using surrogate markers in peripheral blood. We constructed a multiscale mathematical model that explicitly incorporates both intracellular and intercellular HBV infection processes. The model, based on age-structured partial differential equations, integrates experimental data from in vitro and in vivo investigations. By applying this model, we roughly predicted the amount and dynamics of intrahepatic cccDNA within a certain range using specific viral markers in serum samples, including HBV DNA, HBsAg, HBeAg, and HBcrAg. Our study represents a significant step towards advancing the understanding of chronic HBV infection. The noninvasive quantification of cccDNA using our proposed method holds promise for improving clinical analyses and treatment strategies. By comprehensively describing the interactions of all components involved in HBV infection, our multiscale mathematical model provides a valuable framework for further research and the development of targeted interventions.

Force-sensing treadmill gait analysis system can detect gait abnormalities in haemophilia patients without arthropathy.

BACKGROUND: Joint damage in patients with haemophilia (PwH) is commonly assessed by imaging, but few reports have described how structural changes in joints, for example, haemophilic arthropathy (HA)-affect gait ability. OBJECTIVES: We evaluated gait function among PwH with HA, PwH without HA, and people without haemophilia (non-PwH) using a Zebris FDM-T treadmill (FDM-T), an easy-to-use gait assessment instrument with a force sensor matrix. METHODS: The following gait parameters were collected: centre of pressure trajectory intersection (COPi) anterior/posterior variability, COPi lateral variability, COPi anterior/posterior symmetry, COPi lateral symmetry, single-limb support line (SLSL) length, and SLSL variability. Participants walked at their typical gait speed. The physical function of the PwH was assessed by the Hemophilia Joint Health Score (HJHS). Parameters were compared among the three groups. RESULTS: Twelve PwH with HA, 28 PwH without HA, and 12 non-PwH were enrolled. Gait speed significantly differed between groups (non-PwH, 3.1 ± 0.7; PwH without HA, 2.0 ± 0.7; PwH with HA; 1.5 ± 0.4). The COPi anterior/posterior variability, COPi lateral variability, SLSL length, and SLSL variability were greater in the PwH groups than in the non-PwH group. The COPi lateral symmetry differed between PwH with HA and the other groups. The HJHS was not correlated with gait parameters among PwH with HA. CONCLUSIONS: Gait parameters and speed were abnormal in both PwH with HA and PwH without HA. The FDM-T can be used to identify early stages of physical dysfunction that cannot be detected by conventional functional assessments such as the HJHS.

Treatment of Symptomatic Os Supranaviculare in Athletes.

BACKGROUND: Although the incidence of os supranaviculare (OSSN) is generally low, symptomatic OSSN affects athletes. The aim of this study was to assess the variations of OSSN and the results of osteosynthesis between the OSSN and the navicular bone. METHODS: Eleven feet of 10 elite athletes with symptomatic OSSN were treated. There were 3 male and 7 female patients with an average age of 19 years. Eight feet exhibited navicular stress fracture (NSF). Operative treatment was performed in 9 feet of 8 patients and 2 conservatively. Seven OSSNs were fixed with 1 or 2 screw(s) according to their size, using an autologous bone graft. The accompanying NSF was also treated surgically in 4 feet. Foot condition was evaluated using the Japanese Society for Surgery of the Foot (JSSF) midfoot rating scale and sports activity score of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q). RESULTS: The median OSSN was 12.7 mm in width, 5.6 mm in length, and 6.6 mm in height. The dorsal surface of the OSSN required at least 70 mm2 to be fixed using 2 screws. Seven OSSNs of 6 patients treated surgically successfully fused with the navicular. Two small OSSNs that were not stabilized with screws also fused after surgical treatment for NSF. However, one of the 2 OSSNs with NSF treated nonoperatively did not achieve fusion. The patients were followed up for 24-161 months. The median JSSF score improved from 87 to 97.7 postoperatively (P = .00312). The median postoperative SAFE-Q sports score was 84.8. All patients returned to their original activities. CONCLUSION: Our results suggest that osteosynthesis with autologous bone graft was effective for symptomatic OSSNs. Even when the OSSN was small and not suitable for internal fixation, treatment of NSF was effective for union of OSSNs. The OSSN possibly belongs to a part or subtype of NSF. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Safety of biliary drainage with 6-mm metallic stent for preoperative obstructive jaundice in pancreatic cancer: PURPLE SIX STUDY.

BACKGROUND AND AIM: The 10-mm self-expandable metal stent (SEMS) is the standard for endoscopic transpapillary biliary drainage before pancreatic cancer surgery. However, the efficacy of stents thinner than 10 mm has not been adequately validated. Therefore, we aimed to evaluate the safety of a 6-mm fully covered SEMS (FCSEMS) for distal malignant biliary obstruction (DMBO) during preoperative chemotherapy for pancreatic cancer. METHODS: This was a single-arm, multicenter, prospective phase II study of endoscopic transpapillary initial biliary drainage for DMBO before pancreatic cancer surgery. The primary endpoint was stent-related adverse events, and the key secondary endpoint was the non-recurrent biliary obstruction (non-RBO) rate during the observation period for both resectable (R) and borderline resectable (BR) pancreatic cancers. RESULTS: The study enrolled 33 patients, among whom 32 received the study treatment. There were 23 and 9 cases of R and BR pancreatic cancers, respectively. The technical and clinical success rates were 97.0% and 90.1%, respectively. The stent-related adverse event rate was 3.1% (n = 1, acute pancreatitis) (95% confidential interval, 0.00-16.2), which met the criteria to be considered safe. The overall non-RBO rate during the observation period (median 96 days) was 78.1% (82.6% and 66.7% for R and BR pancreatic cancer cases, respectively). CONCLUSIONS: The 6-mm FCSEMS is an extremely safe metallic stent with a low stent-related adverse event rate of 3.1% for preoperative biliary drainage in pancreatic cancer. It is considered the optimal stent for preoperative biliary drainage in terms of the non-RBO rate. UMIN Clinical Trial Registry (UMIN-CTR 000041704).

A novel, small anti-HBV compound reduces HBsAg and HBV-DNA by destabilizing HBV-RNA.

BACKGROUND: Currently, standard treatments for chronic hepatitis B such as nucleos(t)ide analogs (NAs), effectively reduce hepatitis B virus (HBV) loads but rarely result in a functional cure (defined as sustained HBsAg loss). We report the discovery of a novel, 4-pyridone compound, SAG-524, a potent and orally bioavailable small molecule inhibitor of HBV replication. METHODS: The antiviral characteristics and selectivity of SAG-524 and its derivative compound against HBV were evaluated in HBV-infection assays and HBV-infected chimeric urokinase-type plasminogen activator/severe combined immunodeficiency mice with humanized livers (PXB mice), alone or in combination with entecavir. Toxicity studies were conducted in mice and monkeys. RESULTS: SAG-524 reduced HBV-DNA (IC50 = 0.92 nM) and HBsAg (IC50 = 1.4 nM) in the supernatant of the HepG2.2.15 cells. SAG-524 selectively destabilized HBV-RNA via PAPD5, but not GAPDH or albumin mRNA, by shortening the poly(A) tail. PAPD5 may also be involved in HBV regulation via ELAVL1. In a study of HBV-infected PXB mice, SAG-524 produced potent reductions of serum HBsAg and HBcrAg, and the minimum effective dose was estimated to be 6 mg/kg/day. The combination therapy with entecavir greatly reduced HBsAg and cccDNA in the liver due to reduction of human hepatocytes with good tolerability. Administration of SAG-524 to monkeys, up to 1000 mg/kg/day for two weeks, led to no significant toxicity, as determined by blood tests and pathological images. CONCLUSIONS: We have identified SAG-524 as novel and orally bioavailable HBV-RNA destabilizers which can reduce HBsAg and HBV-DNA levels, and possibly contribute a functional cure.

Anatomical Relations of the Perforators from the Descending Lateral Femoral Circumflex Artery and Vastus Lateralis Motor Nerve Branches.

Background: The anterolateral thigh (ALT) flap, which is nourished by perforators from the descending branch of the lateral femoral circumflex artery (P), is one of the most commonly used flaps in soft tissue reconstruction. With the growing use of ALT flaps, attention toward donor-site morbidity has increased in recent years. Damage to the motor nerve branches of the vastus lateralis muscle (N) is one of the causes of donor-site morbidity, particularly muscle weakness. This study investigated the anatomical locations of the P and N in fresh-frozen cadaveric specimens. Methods: This study included 43 cadaver limbs. A silicone rubber compound (30 mL) was injected into the femoral artery to visualize the vessel. The locations of the P and motor points of N were measured to assess the risk of N injury during ALT flap harvesting. Results: There were one to six (mean, 2.7) P and two to seven (mean, 4) N. When the two most proximal perforators were used for flap harvesting, an average of 1.5 motor nerve branches (42%) was damaged because transection of the motor nerve branches was required for flap harvesting. In 33% of the limbs, only one motor nerve branch remained after the flap harvest. However, there were no cases where all motor nerve branches were severed. Conclusion: When an ALT flap with two perforators is harvested, weakness of the vastus lateralis muscle may occur in cases with a small number of motor nerve branches.

Clinical outcomes of reposition flap transfer for fingertip amputation.

PURPOSE: This study aimed to describe the reposition flap for reconstructing fingertip amputation when replantation is not possible. METHODS: This study retrospectively reviewed the records of patients with reposition flap transfers and investigated postoperative clinical outcomes and patient satisfaction. Sixteen patients with fingertip amputations treated with a reposition flap from 2016 to 2020. The mean age at injury was 46 years (range, 26-70 years). Ten cases were treated with oblique triangular advancement flaps, 3 with retrograde-flow digital artery flaps, and 3 with thumb palmar advancement flaps. Postoperative outcomes, including wound healing period and the IP/PIP extension angle, and the presence of grafted bone absorption and patient satisfaction were evaluated as of 3 years after surgery. RESULTS: The average reduction in passive extension angle of the IP/PIP joint was 19°. The average time for complete wound healing was 28 days (range, 18-41 days). The reduction in passive extension angle of the IP/PIP joint was significantly correlated with the wound healing period (r = 0.66, p = 0.01). The absorption of the grafted bone was observed in 3 cases. In these cases, the distal tip of the flap became thin due to flap retraction and an insufficient flap volume. All patients were highly or fairly satisfied with the results of surgery. CONCLUSION: Our findings show that IP/PIP flexion contracture can occur due to delayed wound healing after reposition flap transfer, but the patient satisfaction level was generally high. Therefore, reconstruction using a reposition flap gives acceptable clinical outcomes and high patient satisfaction as a result of medium to long-term.

Anterior Placement of Cages in Posterior Lumbar Interbody Fusion for Obtaining Good Lumbar Lordosis Formation.

Introduction: Posterior lumbar interbody fusion (PLIF) is a common treatment for nerve root disease associated with lumbar foraminal stenosis or lumbar spondylolisthesis. At our institution, PLIF is usually performed with high-angle cages and posterior column osteotomy (PLIF with HAP). However, not all patients achieve sufficient segmental lumbar lordosis (SLL). This study determined whether the location of PLIF cages affect local lumbar lordosis formation. Methods: A total of 59 patients who underwent L4/5 PLIF with HAP at our hospital, using the same titanium control cage model, were enrolled in this cohort study. The mean ratio of the distance from the posterior edge of the cage to the posterior wall of the vertebral body/vertebral length (RDCV) immediately after surgery was 16.5%. The patients were divided into two groups according to RDCV <16.5% (group P) and ≥16.5% (group G). The preoperative and 6-month postoperative slip rate (%slip), SLL, local disk angle (LDA), ratio of disk height/vertebral height (RDV), 6-month postoperative RDCV, ratio of cage length/vertebral length (RCVL), and ratio of posterior disk height/anterior disk height at the fixed level (RPA) were evaluated via simple lumbar spine X-ray. The preoperative and 6-month postoperative Japanese Orthopedic Association (JOA) and low back pain visual analog scale (VAS) scores were also evaluated. Results: Groups G and P included 31 and 28 patients, respectively. The preoperative %slip, SLL, LDA, RDV, JOA score, and low back pain VAS score were not significantly different between the groups. In groups G and P, 6-month postoperative %slip, SLL, LDA, RDV, RDCV, RCVL, and RPA were 3.3% and 7.9%, 18.6° and 15.4°, 9.7° and 8.0°, 36.6% and 40.3%, 21.1% and 10.1%, 71.4% and 77.0%, and 56.1% and 67.7%, respectively. The 6-month postoperative SLL, LDA, RDV, RDCV, RCVL, and RPA significantly differed (p=0.03, 0.02, 0.02, <0.001, <0.001, and <0.001, respectively). Conclusions: Anterior PLIF cage placement relative to the vertebral body is necessary for good SLL in PLIF.

Serum MYCN as a predictive biomarker of prognosis and therapeutic response in the prevention of hepatocellular carcinoma recurrence.

The proto-oncogene MYCN expression marked a cancer stem-like cell population in hepatocellular carcinoma (HCC) and served as a therapeutic target of acyclic retinoid (ACR), an orally administered vitamin A derivative that has demonstrated promising efficacy and safety in reducing HCC recurrence. This study investigated the role of MYCN as a predictive biomarker for therapeutic response to ACR and prognosis of HCC. MYCN gene expression in HCC was analyzed in the Cancer Genome Atlas and a Taiwanese cohort (N = 118). Serum MYCN protein levels were assessed in healthy controls (N = 15), patients with HCC (N = 116), pre- and post-surgical patients with HCC (N = 20), and a subset of patients from a phase 3 clinical trial of ACR (N = 68, NCT01640808). The results showed increased MYCN gene expression in HCC tumors, which positively correlated with HCC recurrence in non-cirrhotic or single-tumor patients. Serum MYCN protein levels were higher in patients with HCC, decreased after surgical resection of HCC, and were associated with liver functional reserve and fibrosis markers, as well as long-term HCC prognosis (>4 years). Subgroup analysis of a phase 3 clinical trial of ACR identified serum MYCN as the risk factor most strongly associated with HCC recurrence. Patients with HCC with higher serum MYCN levels after a 4-week treatment of ACR exhibited a significantly higher risk of recurrence (hazard ratio 3.27; p = .022). In conclusion, serum MYCN holds promise for biomarker-based precision medicine for the prevention of HCC, long-term prognosis of early-stage HCC, and identification of high-response subgroups for ACR-based treatment.

Optimal retractor insertion point for nerve safety during total hip arthroplasty: an anatomical study on the femoral and sciatic nerves in relation to hip motion.

BACKGROUND: Nerve injury is one of the most serious complications of total hip arthroplasty (THA). It is suspected to be a result from nerve compression or direct injury caused by an acetabular retractor. The anatomical relationship between the acetabular rim and the femoral and sciatic nerves, including hip motion, has not been investigated. This study aimed to identify the optimal position for retractor insertion during THA to prevent nerve damage. METHODS: A total of 28 hip joints from 14 freshly frozen cadavers were used. Using an anterolateral approach, each cadaver was immobilised in the lateral decubitus position and deployed to measure the distance between the nerves and the acetabular rim, while the hip joint was changed to the extension, neutral, and flexion positions. RESULTS: Three femoral nerves were closest to the anterior margin of the acetabulum at 90° and 120° of extension and farthest away at 30° of flexion. The sciatic nerve was closest to the posterior margin of the acetabulum at 90° and 120° of flexion and farthest away at 30° and 150° of extension compared with the other points. CONCLUSIONS: To prevent nerve damage during THA, we suggest that the retractor be inserted at the points where the nerves are the farthest away, such as at 30° and 150°. The femoral and sciatic nerves vary in their movements depending on the hip position. Therefore, the safe insertion of a retractor is recommended for hip flexion of the femoral nerve and extension of the sciatic nerve. Additionally, it is important to carefully insert the retractor along the acetabular margin without penetrating the joint capsule. Overall, this study provides valuable insights into the anatomical location and movement of the femoral and sciatic nerves in relation to hip motion and can help inform surgical techniques for safer THA.

Arthroscopy-Assisted Surgery for Trapeziometacarpal Osteoarthritis.

Background: Functional outcomes of patients who underwent arthroscopy-assisted surgery for trapeziometacarpal osteoarthritis were reported. Methods: We included 24 consecutive patients (6 males and 18 females) who underwent surgery and postoperative hand therapy at our hospital between April 2012 and March 2018. For functional evaluation, we used the Purdue Pegboard Test (PPT), grip and pinch strength, range of motion of the thumb, visual analogue scale (VAS) for thumb pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Japanese version of the Patient-Rated Wrist Evaluation (PRWE-J) preoperatively and 3 months postoperatively. Results: The mean PPT rating improved from 12.3 to 13.3, the VAS score from 51 to 16, the QuickDASH score from 48 to 30 and the PRWE-J score from 55 to 29. All the improvements were statistically significant. There was a moderate positive correlation between the magnitude of improvement in PPT and QuickDASH scores. Conclusions: Arthroscopic intervention and associated hand therapy were effective in achieving early postoperative relief of thumb pain and in improving hand dexterity and activities of daily living. Level of Evidence: Level IV (Therapeutic).

Antiviral Therapy Utilization and 10-Year Outcomes in Resected Hepatitis B Virus- and Hepatitis C Virus-Related Hepatocellular Carcinoma.

PURPOSE: There are limited data on antiviral treatment utilization and its impact on long-term outcomes of hepatitis B virus (HBV)- and hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) after hepatic resection. We aimed to determine the utilization and impact of antivirals in HBV- and HCV-related HCC. METHODS: This cohort study included 1,906 participants (1,054 HBV-related HCC and 852 HCV-related HCC) from 12 international sites. All participants had HBV- or HCV-related HCC and underwent curative surgical resection. The primary outcome was the utilization of antiviral therapy, and the secondary outcome was long-term overall survival (OS). RESULTS: The mean (±standard deviation [SD]) age was 62.1 (±11.3) years, 74% were male, and 84% were Asian. A total of 47% of the total cohort received antiviral therapy during a mean (±SD) follow-up of 5.0 (±4.3) years. The overall antiviral utilization for participants with HBV-related HCC was 57% and declined over time, from 65% before 2010, to 60% from 2010 to 2015, to 47% beyond 2015, P < .0001. The overall utilization of antivirals for HCV-related HCC was 35% and increased over time, from 24% before 2015 to 74% from 2015 and beyond, P < .0001. The 10-year OS was lower in untreated participants for both HBV (58% v 61%) and HCV participants (38% v 82%; both P < .0001). On multivariable Cox regression analysis adjusted for relevant confounders, antiviral therapy initiated before or within 6 months of HCC diagnosis was independently associated with lower mortality in both HBV- (adjusted hazard ratio [aHR], 0.60 [95% CI, 0.43 to 0.83]; P = .002) and HCV-related HCC (aHR, 0.18 [95% CI, 0.11 to 0.31]; P < .0001). CONCLUSION: Antiviral therapy is associated with long-term survival in people with HBV- or HCV-related HCC who undergo curative resection but is severely underutilized.

Chronic intestinal pseudo-obstruction due to adult-onset acquired isolated hypoganglionosis with muscular atrophy in the small intestine: a case report and review of literature.

BACKGROUND: Chronic intestinal pseudo-obstruction (CIPO) is a rare intestinal disorder characterized by impaired propulsion of the digestive tract and associated with symptoms of intestinal obstruction, despite the absence of obstructive lesions. CIPO includes several diseases. However, definitive diagnosis of its etiology is difficult only with symptoms or imaging findings. CASE PRESENTATION: A 56-year-old man was referred to our hospital due to a 3-year history of continuous abdominal distention. Imaging, including computed tomography of the abdomen, and endoscopy revealed marked dilatation of the entire small intestine without any obstruction point. Therefore, he was diagnosed with CIPO. Since medical therapy didn't improve his symptoms, enterostomy and percutaneous endoscopic gastro-jejunostomy were performed. These procedures improved abdominal symptoms. However, he required home central venous nutrition due to dehydration. The pathological findings of full-thickness biopsies of the small intestine taken during surgery revealed decreased number and degeneration of ganglion cells in the normal plexus. These findings led to a final diagnosis of CIPO due to acquired isolated hypoganglionosis (AIHG). CONCLUSIONS: Here, we report the case of a patient with CIPO secondary to adult-onset AIHG of the small intestine. Since AIHG cannot be solely diagnosed using clinical findings, biopsy is important for its diagnosis.

Anatomical quantitative evaluation of popliteal artery visualization during medial approach in supine position.

PURPOSE: The medial approach to the popliteal artery has been less commonly used than the posterior approach in surgical repair of traumatic popliteal injury. This study was performed to quantitatively evaluate the visual field of the popliteal artery obtained by staged myotendotomy in the medial approach to the popliteal artery. METHODS: Twenty legs of fresh-frozen adult cadavers were dissected using the medial approach to the popliteal artery. In stage 1, the popliteal artery was exposed between the vastus medialis and sartorius muscles without myotendotomy. In stage 2, the medial head of the gastrocnemius muscle was dissected. In stage 3, the tendons of the sartorius and semimembranosus muscles were dissected. In stage 4, the tendons of the gracilis and semitendinosus muscles were dissected to fully expose the popliteal artery. The length of the popliteal artery that could be visualized in each stage was measured. RESULTS: The anatomical length of the popliteal artery from the hiatus of the adductor magnus to the tendinous arch of soleus muscle ranged from 15 to 20 cm (mean, 16.3 cm). On average, 45%, 59%, 72%, and 100% of the popliteal artery were visualized in stage 1, 2, 3, and 4, respectively. CONCLUSIONS: The medial approach to the popliteal artery has the advantage of being performed in the supine position, but it requires multiple myotendotomies around the knee. The results of this study may serve as a reference for myotendotomy depending on the site of injury to the popliteal artery.

Serum angiopoietin-2 levels predict the development of hepatocellular carcinoma following hepatitis C virus eradication using direct-acting antiviral agents.

INTRODUCTION: Our previous studies showed that serum angiopoietin-2 (Ang-2) and C-X-C motif chemokine ligand 10 (CXCL10) levels predicted improvement in liver fibrosis following sustained virological response (SVR) of hepatitis C virus (HCV) obtained with administration of with direct-acting antiviral agents (DAAs). These levels were evaluated retrospectively as predictive indicators of hepatocellular carcinoma (HCC) development following SVR. METHODS: We enrolled individuals from a historical cohort of 89 chronic HCV patients without history of HCC at baseline and with SVR following DAA therapy and had baseline serum levels of Mac-2 binding protein glycosylation isomer ≥ 2.0 C.O.I. RESULTS: Multivariate analyses revealed that only the Ang-2 level at 24 weeks following the end of treatment (EOT24W) was significantly related to HCC development (hazard ratio 2.27; P = 0.003). This result was reproduced in individuals without history of HCC and with advanced liver fibrosis (M2BPGi level ≥ 3.3 C.O.I. at baseline). Time-dependent receiver operating characteristic curve analyses for the future risk of developing HCC within 5 years of follow-up (5y-HCC) showed the best cut-off Ang-2 level at the EOT24W was 2,780 pg/mL, and significantly stratified the cumulative incidence of HCC (≥ 2,780 vs. < 2,780 pg/mL, 5y-HCC: 45.5 vs. 8.2%, P < 0.001). CONCLUSIONS: At the EOT24W, serum Ang-2 level predicts the likelihood of developing HCC following SVR to DAA therapy.

Reliability of the Risser+ grade for assessment of bone maturity in pediatric scoliosis cases: Investigation using standing and supine whole-spine radiograph.

BACKGROUND: Although several radiography-based systems for assessing skeletal maturity are available to clinicians, the classical Risser grading system remains a clinical gold standard. For scoliosis follow-up, a standing whole-spine radiograph is usually used. However, in our clinical practice, we have occasionally encountered cases in which ossification of the iliac crest is seen differently in the standing and supine whole-spine radiography. Here, we aimed to clarify the reliability of the Risser+ grading system for supine versus standing position radiographs. METHODS: This study recruited patients with all types of scoliosis who had been radiographed in both the standing and supine positions. We retrospectively evaluated the Risser+ grade of standing and supine whole-spine radiographs taken consecutively. Kappa statistics were computed to investigate the agreement between standing and supine Risser+ grades for this study. RESULTS: We evaluated 111 patients (age: 12.6 ± 2.0; male-to-female = 23:88). The Kappa value for the standing and supine Risser+ grade systems was 0.74. The degree of agreement between the two positions for each Risser+ grade revealed high agreement for grades 0 and 5 in all cases, whereas grades 2 and 3 had low agreement. CONCLUSIONS: Overall, there was substantial agreement between the Risser+ grades assigned to standing and supine position radiographs. However, disagreement was observed between standing and supine position radiographs assigned Risser+ grades of 2 or 3. Therefore, we have found a wide range in the visibility of iliac apophysis ossification of the iliac depending on the posture, and there are limitations in assessing bone maturity using the Risser+ grade alone. Clinicians should use other evaluation systems, in addition to the Risser+ system, to achieve a more accurate bone maturity assessment, especially for cases with standing position radiographs assigned Risser grades of 2 or 3.

Anterior Ankle Impingement Syndrome With Spur Fragmentation: Is It an Os Talotibiale?

Background: Bone fragments are often found in ankles with anterior bony impingement. However, whether they are detached osteophytes or accessory bones remains unknown. Methods: Among the 66 continuously enrolled cases of ankles with anterior bony impingement, 32 had a fragment located at the anterior margin of the tibia. The cases of posterior impingement, lateral instability, osteochondral lesions, or free bodies simultaneously treated were excluded. The enrolled subjects were classified into 2 groups: ankles without (group A) and with remarkable spurs (group B). The patients' backgrounds, location of the fragments, clinical scores, and other parameters required to resume sports were compared. The Japanese Society for Surgery of the Foot (JSSF) ankle rating scale was used to evaluate preoperative and postoperative ankle conditions, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) was used to evaluate postoperative sports abilities. Results: Eight (seven subjects) and 11 ankles were classified into groups A and B, respectively, and the mean age of the 18 patients was 25.4 (range, 16-37) years. No statistical differences in patient backgrounds or fragment sizes between the groups existed. In group A, the fragments were located on the lateral plateau in 7 of the 8 ankles, whereas in group B, their locations varied. The patients were followed up for a median of 48 months (range, 24-168). No complications were observed. The postoperative JSSF and SAFE-Q sports activity scores were significantly higher in group A than in group B (P <.01 and <.001, respectively). The postoperative term to return to their original sports activities was significantly shorter in group A (P < .05). Conclusion: Anterior bony fragments of the ankle without a remarkable spur were located at a specific site, and the results of arthroscopic treatment were better than in those with remarkable spurs. Such a fragment may be called an os talotibiale. Level of Evidence: Level III, retrospective cohort study.