Management of bone loss in acute severe open tibial fractures: a retrospective study of twenty nine cases-a treatment strategy with bone length preservation.

PURPOSE: The present study investigated the outcomes of bone loss associated with acute open tibial fractures classified as Gustilo-Anderson classification grade III B (GIIIB) using a bone length preservation strategy. METHODS: Among acute GIIIB open tibial fractures, 29 limbs of 29 patients requiring bone loss treatment were included. The reconstruction methods for bone loss were selected among the Masquelet technique (MT), bone transport (BT), acute shortening followed by gradual lengthening (ASGL), and free vascularized fibula graft (FVFG). Primary outcome measures were the rate of bone union and time to bone union. RESULTS: The median radiographic apparent bone gap (RABG) was 46.75 mm. Bone loss was treated with ASGL only in two patients in whom it was not possible to cover large soft tissue defects by a single free latissimus dorsi (LD) myocutaneous flap (with the serratus anterior (SA) muscle). The other 27 patients underwent soft tissue reconstruction and bone loss treatment with the preservation of bone length, including the MT for 23, BT for six, and FVFG for one. The bone union rate was 75.9%, and the median time to bone union was six months. Salvage surgeries were performed on all seven patients with nonunion; all of whom eventually achieved bony union. CONCLUSION: Bone loss associated with acute GIIIB open tibial fractures were treated with "bone length preservation" if the size of the soft tissue defect was less than the size that was covered by a single LD myocutaneous flap (with the SA muscle).

Positivity rate of interferon-γ release assays for estimating the prevalence of latent tuberculosis infection in renal transplant recipients in Japan.

Renal transplant recipients are at increased risk of reactivating latent tuberculosis infection (LTBI) and developing active tuberculosis. QuantiFERON®-TB Gold Plus (QFT-Plus) has two TB-specific antigens tubes (TB1 and TB2). TB1 elicits CD4 T-cell response, and TB2 elicits both CD4 and CD8 T-cells responses, with expected increased sensitivity. The aim of this study was to estimate the prevalence of LTBI in renal transplant recipients in Japan. We conducted a cross-sectional study by using two interferon-γ release assays (IGRAs), QFT-Plus and T-SPOT®.TB (TSPOT). One hundred thirty-five recipients were prospectively enrolled. The median age was 49 years (range: 20 to 79). The positivity rates of QFT-Plus and TSPOT were 5.9% (95%CI 3.0-11.3) and 3.7% (95%CI 1.6-8.4), respectively, with no significant difference. The concordance rate was 95.5% (κ coefficient, 0.76). Age of 60 years and higher was related to the higher positivity rate in both QFT-Plus and TSPOT. The positivity rates of TB1 and TB2 were 5.1% (95%CI 2.5-10.2) and 5.9% (95%CI 3.0-11.2), respectively, with no significant difference. The concordance rate was 99.3% (κ coefficient, 0.93). TB2 did not show a higher positivity rate compared with TB1. The estimated prevalence of LTBI by using the both IGRAs was 3.7-5.9% in renal transplant recipients. These results were equivalent to the IGRAs positivity rate in the general Japanese population, even under the condition of immunosuppressive therapy. In consideration of the higher risk of developing active TB from LTBI, we can use both IGRAs as acceptable tools for LTBI diagnosis in renal transplant recipients.

Health Effects of Toner Exposure Among Japanese Toner-Handling Workers: A 10-Year Prospective Cohort Study.

The main objective of this study was to evaluate the risk of the respiratory diseases, i.e. pneumoconiosis, lung fibrosis, granulomatous pneumonitis, lung cancer and bronchial asthma, which have been reported as related to toner exposure. The second main objective was to clarify the association between toner exposure and parameters related with toner-handling worker's health. We conducted a 10-year prospective cohort study from 2004 to 2013 in 296 Japanese toner-handling workers. The evaluation of toner exposure and medical health check were performed once a year. There was no obvious evidence of occurrence of lung diseases. We also investigated several health parameters to recognize the change of respiratory health before onset of pneumoconiosis, lung fibrosis, lung cancer and bronchial asthma. However there were some sporadic statistically significant findings, to bring all health parameters, we did not find obvious evidence that toner exposure would cause adverse health effects as a whole. We concluded that the possibility that toner exposure would cause adverse health effects was quite low.

Comparison of interferon-γ release assays, QuantiFERON TB-GIT and T-Spot.TB, in renal transplantation.

Renal transplant recipients are at increased risk of reactivating latent tuberculosis infection (LTBI) and progressing to active tuberculosis (TB). This study was conducted in National hospital for tuberculosis and renal transplantation (RT) in Japan. The purpose is to compare two interferon-γ release assays (IGRAs), QuantiFERON®-TB Gold in Tube (QFT) and T-SPOT®.TB (TSPOT), in patients after renal transplantation for detecting latent TB infection (LTBI). Total 92 renal transplant recipients (median age 46 years, range 17-75) were prospectively enrolled, and QFT and TSPOT were concurrently examined. Total subjects were 92 patients (median age 46 years, range 17-75). The positive rate in QFT and TSPOT were 6.5% (95% confidence interval (CI) 3.0-13.5) and 2.2% (95% CI 1.0-7.6), respectively. There was a significant difference in IGRAs positivity (P < 0.05). The negative rate in QFT and TSPOT were 91.3% (95% CI 83.8-95.5) and 95.7% (95% CI 89.3-98.3), respectively. There was no significant difference in IGRAs negativity. No patients among either IGRAs negative patients developed active TB during median follow-up of 994 days. Neither QFT nor TSPOT reaches estimated TB infection rate in Japan, especially elderly recipients aged 60 year-old or more. Therefore, both IGRAs might underestimate LTBI owing to immune suppressive therapy and aging. Physicians for renal transplantation need to understand the characteristics of both IGRAs and pay attention to the possibility of developing active TB even in patients of negative IGRAs results.

Fatal overdose from synthetic cannabinoids and cathinones in Japan: demographics and autopsy findings.

BACKGROUND: Sixty-one autopsy cases involving cathinones and/or cannabinoids (synthetic cathinones/cannabinoids) use have been reported. However, little is known about the demographics and autopsy findings in fatal synthetic cathinones/cannabinoids users. OBJECTIVES: To elucidate demographic and autopsy findings (i.e. major organ pathology and causes of death) in synthetic cathinones/cannabinoids cases. METHODS: We reviewed forensic autopsy reports in Department of Legal Medicine of Tokyo Women's Medical University (Tokyo, Japan) between 2011 and 2015 (a total of 359). We compared demographic and autopsy findings between synthetic cathinones/cannabinoids and methamphetamine cases (as control subjects). RESULTS: There were 12 synthetic cathinones/cannabinoids cases and 10 methamphetamine cases. Synthetic cathinones/cannabinoids users were significantly younger than methamphetamine users (p < 0.01), and there were no cases that used both synthetic cathinones/cannabinoids and methamphetamine. Acute intoxication and cardiac ischemia were the two most prominent causes of death in both synthetic cathinones/cannabinoids users and methamphetamine users. Excited delirium syndrome and pulmonary aspiration were found only in synthetic cathinones/cannabinoids cases. CONCLUSIONS: The populations of synthetic cathinones/cannabinoids and methamphetamine users who died of an overdose are different in Japan. Acute intoxication, cardiac ischemia, excited delirium syndrome, pulmonary aspiration, and drowning are the major autopsy findings in synthetic cathinones/cannabinoids-related death. Clinicians shuld be aware of these potentially fatal complications in the medical management of synthetic cathinones/cannabinoids users.

Photochemically-induced C-C bond formation between tertiary amines and nitrones.

Photoexcited nitrones serve as excellent electron acceptors as well as radical acceptors in the presence of tertiary amines to give ß-amino hydroxylamines via photochemically-induced direct sp(3) C-H functionalization of the tertiary amines. The combined use of an organophotosensitizer and photoirradiation was highly effective in accelerating addition reactions. Several nitrones and tertiary amines were successfully utilized to give ß-amino hydroxylamines in good yield. Highly regioselective generation of primary α-aminoalkyl radicals based on Lewis's stereoelectronic rule and diastereoselective addition reactions of primary α-aminoalkyl radicals with nitrones were successfully achieved. Furthermore, a highly diastereoselective reaction of an α-aminoalkyl radical with a chiral (E)-geometry-fixed α-alkoxycarbonylnitrone was performed.

Focal segmental glomerular sclerosis recurrence with massive proteinuria and anuria immediately after kidney transplantation.

Here, we report a case of focal segmental glomerular sclerosis (FSGS) recurrence immediately (47 minutes) after transplantation. A 1-hour biopsy specimen showed large periodic acid-Schiff-positive granules within the cells of the swollen proximal tubule, while electron microscopy revealed podocyte swelling and partial foot process effacement. These findings were worse on day 2 biopsy. Massive proteinuria and anuria were then observed. Two courses (2 × 2 times) of plasmapheresis and rituximab were administered, and the graft function gradually recovered. A day 22 biopsy specimen showed improvement in findings compared to those observed on day 2. One year after transplantation, no signs of FSGS recurrence are evident, and graft function remains good.

Bone and soft tissue reconstruction with tendon balance in severe foot trauma.

In severe foot trauma, it is difficult to determine the level of amputation when the crush injury is severe. We report a case of amputation near Lisfranc that achieved forefoot amputation-like results by using bone and soft tissue reconstruction while considering tendon balance. The patient was a 40-year-old male. The patient's left leg was caught in a garbage truck and sustained a crush injury. The second to fifth metatarsals were amputated at the diaphysis, and a high degree of instability of the Lisfranc joint was observed. A high degree of contamination was detected in the patient's wound, and the second to fifth toes were amputated at the Lisfranc joint during the initial treatment. The ends of the tibialis anterior, tibialis posterior and peroneus longus were preserved. On day 5 in the hospital, Lisfranc joint fixation of the hallux, amputation of the first metatarsal and reconstruction of the peroneus brevis were performed. On day 13, extensor hallucis longus tendon transfer and free anterolateral thigh flap were performed. On day 80, the patient was able to walk in regular shoes or non-orthopedic shoes. One year after reconstructive surgery, the patient had an average SAFE-Q score of 86.2 and mild varus deformity of the foot remained. In cases of severe foot trauma, the aim of reconstruction should be partial forefoot amputation whenever possible.

Evaluation of Hand-Arm Vibration Syndrome Owing to Nerve Conduction Study and Cumulative Exposure Index-A 2.5-Year Cohort Study.

OBJECTIVE: This study aims to clarify the relationship between peripheral neuropathy in hand-arm vibration syndrome and cumulative exposure index. METHODS: 68 participants without symptoms were surveyed. The participants were divided into three groups based on past and current vibration exposure (VE). RESULTS: Comparison among groups according to past VE showed that the median and ulnar sensory nerve conduction velocities and median sensory nerve action potential (SNAP) amplitude were significantly lower in past high and low exposure groups than in the past nonexposure group. Comparison among groups according to current VE showed that the median and ulnar SNAP amplitudes were significantly lower in the current high exposure group than in the current low or nonexposure group. CONCLUSIONS: Vibration tool handlers have potential peripheral nerve lesions at a certain stage without subjective symptoms of the finger.

Surgical delay in reverse sural artery flap prevents congestion of the flap: a case report of the stepwise delay method.

We performed reverse sural artery flap (RSAF) with the stepwise delay method, cutting the vascular pedicle step by step, as the patient had a high risk of flap necrosis. Surgical delay in RSAF is anticipated to prevent not only flap cyanosis but also flap congestion.

[Evaluation of self-administered questionnaire items used in regular health check-ups at the workplace by occupational health professionals].

OBJECTIVE: Currently, there is no standardized questionnaire for regular workplace health check-ups in Japan. We considered that there are several issues associated with this, including the possibility that the questionnaire items are not useful for occupational health staff. Therefore, our study aimed to examine the questionnaire items required in regular health check-ups from the occupational health practice perspective and prepare a draft of a standardized medical questionnaire. The ultimate goal is to promote integrated management and utilization of the health-related information obtained from the questionnaire in the future. METHODS: This non-interventional study, conducted from February 2018 to November 2020, examined the questionnaire items for the regular health check-up using the Delphi method. Twenty-two occupational health professionals, including occupational physicians and nurses with qualifications in occupational health, participated in the study. The self-administered questionnaires used by contracted industrial health associations across Japan were obtained, and items from all questionnaires were extracted. A survey questionnaire was then developed, consisting of eight primary headings: "personal attributes," "work-related information and work history," "life history and subjective symptoms," "current and past medical history," "family history," and "pregnancy status," with a total of 589 items. Participants were asked to rate the degree of necessity for each item, excluding the items in "personal attributes" and "pregnancy status." The items with low ratings were excluded, and the remaining items were redesigned and distributed to the participants with the tabulated results. This process was repeated three times to allow the participants to rate the necessity of the items consistently. The questionnaire items with a consensus ratio exceeding 70% on the third try were adopted. The final adopted questionnaire items were again reviewed by the participants and agreed upon by all. RESULTS: A total of 85 items were adopted under five primary headings, including 12 items for "work-related information and work history," 11 for "life history," 22 for "subjective symptoms," 37 for "current medical history," and three for "past medical history." CONCLUSION: The items for the regular health check-up were finally adopted under the primary headings of "work-related information and work history," "subjective symptoms," and "current medical history." We assumed that these items provide an overview of health information that can be utilized in occupational health practice. Based on our findings, there is a need to develop a standardized questionnaire for regular health check-ups and to consider the management and utilization of workers' health information.

Enol ethers as substrates for efficient Z- and enantioselective ring-opening/cross-metathesis reactions promoted by stereogenic-at-Mo complexes: utility in chemical synthesis and mechanistic attributes.

The first examples of catalytic enantioselective ring-opening/cross-metathesis (EROCM) reactions that involve enol ethers are reported. Specifically, we demonstrate that catalytic EROCM of several oxa- and azabicycles, cyclobutenes and a cyclopropene with an alkyl- or aryl-substituted enol ether proceed readily in the presence of a stereogenic-at-Mo monopyrrolide-monoaryloxide. In some instances, as little as 0.15 mol % of the catalytically active alkylidene is sufficient to promote complete conversion within 10 min. The desired products are formed in up to 90% yield and >99:1 enantiomeric ratio (er) with the disubstituted enol ether generated in >90% Z selectivity. The enol ether of the enantiomerically enriched products can be easily differentiated from the terminal alkene through a number of functionalization procedures that lead to the formation of useful intermediates for chemical synthesis (e.g., efficient acid hydrolysis to afford the enantiomerically enriched carboxaldehyde). In certain cases, enantioselectivity is strongly dependent on enol ether concentration: larger equivalents of the cross partner leads to the formation of products of high enantiomeric purity (versus near racemic products with one equivalent). The length of reaction time can be critical to product enantiomeric purity; high enantioselectivity in reactions that proceed to >98% conversion in as brief a reaction time as 30 s can be nearly entirely eroded within 30 min. Mechanistic rationale that accounts for the above characteristics of the catalytic process is provided.

One incision-two windows approach for fixation of multifragmentary coronoid process fracture of the ulna: A case report.

Since the range of access of each surgical approach around the elbow has limitations, it is difficult to treat all types of fractures using only one approach. In the case reported herein, anterior and medial fragments of the comminuted ulnar coronoid process fracture were treated by preparing two access routes through one skin incision and effectively performing the buttress plating of each fragment. The subject was a 27-year-old female who sustained a fracture of the coronoid process of the right ulna by falling during snowboarding. Computed tomography showed the concurrence of a type 2 subtype III and type 3 subtype I ulnar coronoid process fracture according to the O'Driscoll classification. The coronoid process was split into 3 parts: a fragment consisting of the anteromedial facet and upper half of the sublime tubercle (fragment 1), a central fragment including the tip (fragment 2), and a fragment extending from the radial side of the tip to the base of the coronoid process (fragment 3). A 12-cm-long skin incision was made on the anteromedial side of the elbow joint. The region of the anteromedial facet and sublime tubercle was reached by passage between the palmaris longus/flexor digitorum superficialis and humeral head of flexor carpi ulnaris using the over-the-top approach. Fragment 1 was fixed with a buttress plate. Using the anterior approach, the brachialis was then longitudinally split through by passage between the biceps and neurovascular bundle, fragments 2 and 3 were fixed together with a buttress plate. The "one incision-two windows" approach, which provides two approaches (the over-the-top window and the anterior window) by a single skin incision, was implemented for a multifragmentary ulnar coronoid process fracture. This approach is considered to offer access from the front to each of the anterior and medial fragments and permits appropriate buttress plate fixation.

A novel technique for stabilising sacroiliac joint dislocation using spinal instrumentation: technical notes and clinical outcomes.

PURPOSE: Currently, sacroiliac joint dislocations, including crescent fracture-dislocations, are treated using several techniques that have certain issues. We present the technical details and clinical outcomes of a new technique, anterior sacroiliac stabilisation (ASIS), performed using spinal instrumentation. METHODS: ASIS is performed with the patient in a supine position via the ilioinguinal approach. The displacements are reduced and fixed by inserting cancellous screws from the sacral ala and iliac brim; the screw heads are bridged using a rod and locked. We performed a retrospective review of patients with iliosacral disruption who underwent ASIS between May 2012 and December 2020 at two medical facilities. The patients were assessed for age, sex, injury type, associated injuries, complications, functional outcome by evaluating the Majeed pelvic score after excluding the sexual intercourse score and fracture union. RESULTS: We enrolled 11 patients (median age: 63 years). The median operative time was 195 min, median blood loss was 570 g, and eight patients (72.3%) required blood transfusion. The sacral and iliac screws had a diameter of 6.0-8.0 mm and 6.2-8.0 mm, and a length of 50-70 mm and 40-80 mm, respectively. Bone union was achieved with no marked loss of reduction in the median follow-up period of 12 months in all cases. The median Majeed score at the final follow-up was 85/96. CONCLUSION: ASIS is a rigid internal fixation method that provides angular stability. Despite invasiveness issues compared to iliosacral screw fixation, this method is easy to confirm and achieves precise reduction.

Fracture dislocation of the ankle with posterior tibial tendon entrapment within the tibiofibular interosseous space: A case report.

In rare cases of ankle fracture dislocation, the posterior tibial muscle tendon (TP tendon) is incarcerated between the tibia and fibula, thereby impeding reduction. Here we describe a case that presented with such a condition, in which ankle reduction was achieved and surgical repair of the incarcerated TP was delayed. The subject was a 30-year-old male who sustained a fracture dislocation of the left ankle (AO:44-C1.3) in a motorbike accident. After repairing the ankle dislocation, external fixation was performed and osteosynthesis was conducted 10 days after the injury. Plate fixation for the fibula fracture and tight rope fixation for the separation between the tibia and fibula were performed; however, internal fixation for the medial malleolus fracture was delayed because the skin on the medial side of the ankle was in poor condition. One month after the injury, osteosynthesis of the medial malleolus was performed, and the TP tendon was identified in the fracture site. After removing the incarcerated tendon, good reduction of the medial malleolus was achieved, and thus, internal fixation and wound closure could be performed. Re-examination revealed that the TP tendon had an abnormal course. After 3 months, upon re-exposing the entire length of the TP tendon, the TP tendon was incarcerated between the tibia and fibula. To date, although several cases have been reported regarding TP tendon incarceration caused by fracture dislocation of the ankle, no study has reported the anatomical repair of the ankle, regardless of tendon incarceration. In our case, rotational displacement of the medial malleolus fracture remained when the second surgery was completed; however, the presence of some type of incarcerated tissue was suspected. Because leaving the incarcerated TP tendon untreated can cause irreversible long-term complications, early anatomical repair is recommended.

Delayed neurological signs following isolated parasagittal injury in asphyxia at term.

BACKGROUND: Parasagittal cerebral injury is a type of cerebral injury in term infants, which is characterized by the predominant injury of the arterial border zones of the anterior, middle and posterior cerebral arteries, however its early clinical manifestation is mostly unclear. AIM: To understand early clinical features of parasagittal cerebral injury. METHODS: The clinical details of 18 newborn infants who were diagnosed as having parasagittal cerebral injury on magnetic resonance imaging (MRI). Eleven infants had localized injury within parasagittal regions ("Limited" group), 7 infants had diffuse extensive injury involving the deep gray matter and/or periventricular white matter ("Extensive" group). These infants were compared with 9 infants with perinatal asphyxia without MRI abnormalities ("Normal" group). RESULTS: There was no significant difference in the rate of cardiotocographic abnormalities, low Apgar scores, low blood pH and base excess, and the requirement for mechanical ventilation among three groups. Compared with the Normal group, fewer infants in the Limited group developed neonatal encephalopathy within an hour after birth. Neonatal seizures were more frequent in the Limited and the Extensive groups. Hepatic and/or renal dysfunction was more often observed in the Limited group. Cerebral palsy and/or mental retardation were common in the Extensive group. Electro-cortical depression was more in the Extensive group. Progressive suppression of electro-cortical activity was common within infants in the Limited group (33%) and the Extensive group (60%). CONCLUSION: Infants with parasagittal cerebral injury developed serious neurological abnormalities despite less serious physiological and neurological manifestation shortly after birth, suggesting the importance of careful longitudinal observation of asphyxiated infants.

The respiratory effects of toner exposure according to long-term occupational toner handling history: A longitudinal analysis, 2004-2013.

OBJECTIVES: This report shows the relationship between toner exposure and respiratory effects for individuals with a longterm occupational toner-handling history, from 2004 to 2013. MATERIAL AND METHODS: Authors studied 752 Japanese male workers in toner handling workshops. A total of 673 men who participated in an annual monitoring survey were analyzed in this study. The following monitoring was performed in the same season each year: personal exposure measurements, biological markers, respiratory function tests, a chest X-ray, chronic respiratory symptoms and incidences of respiratory diseases. To evaluate the toner exposure effect, the exposure categories suitable for each evaluation index were established. RESULTS: For those with an occupational toner-handling history, the mean occupational toner-handling period was 14.36 years (standard deviation = 6.62); one participant had 35 years of exposure, which was the longest and one participant had 1 year of exposure which was the shortest. There were no statistically significant differences in the rate of change of respiratory function tests. An ANOVA conducted on blood and urine test results showed that statistically significantly differences were observed for a few items but all the values were very low and within the standard range. CONCLUSIONS: Authors conducted a 10-year ongoing study, but no obvious negative influences on health were attributed to toner exposure. In a work environment where adequate administrative controls are in place, personal toner exposure levels may be expected to be low, with no adverse effects on human health. Int J Occup Med Environ Health 2018;31(6):809-822.