Multisystem inflammatory syndrome in children (MIS-C) is a severe multiple organ system inflammation, including circulatory and gastrointestinal organs, which occurs following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, with Kawasaki disease (KD)-like symptoms. However, unlike the Delta variant, there have been few reported cases of MIS-C due to the SARS-CoV-2 Omicron variant. Here, we report a case of MIS-C following SARS-CoV-2 Omicron variant (BA1) infection. A 12-month-old Japanese boy who had been exposed to his sister who was infected with SARS-CoV-2 a week earlier presented with a 5-day history of fever, five KD-like symptoms except for extremity symptoms, no redness at the Bacille Calmette–Guérin vaccination site, and diarrhea. Laboratory tests showed slightly elevated serum inflammatory markers and SARS-CoV-2 Omicron variant (BA1) positivity confirmed through a polymerase chain reaction test, which are consistent with the WHO MIS-C criteria. Intravenous immunoglobulin (2g/kg) and oral aspirin (30mg/kg/day) were administered. During hospitalization, shock-like symptoms and echocardiographic abnormalities were not observed. A case of MIS-C associated with the Omicron variant, resembling ours had been reported. This case presented with KD-like symptoms following a mild clinical course without shock-like symptoms and echocardiographic abnormalities. This suggests that the Omicron variant of SARS-CoV-2 infection is less severe than the Delta variant, subsequently reducing MIS-C severity. The patient met all of the MIS-C criteria set by the WHO but failed to meet those set by the Centers for Disease Control and Prevention and pediatric inflammatory multisystem syndrome criteria by the Royal College of Pediatrics and Child Health. This suggests that mild MIS-C can only be diagnosed by following the WHO criteria. In conclusion, MIS-C due to the Omicron variant may be milder than that caused by the Delta variant and may be more difficult to distinguish from KD.
For individuals attempting suicide and self-harm, appropriate assessment and treatment interventions are essential to prevent reattempts. Patients involuntarily admitted to a psychiatric hospital by order of the prefectural governor frequently experience severe psychiatric symptoms and face several problems and difficulties. This retrospective study involved surveying 412 patients who were involuntarily admitted to our hospital from January 1, 2010 to March 31, 2022 by order of the prefectural governor for self-harm or suicide attempts. Of these, 98 patients continued treatment at our facility ("our hospital group") and 314 patients were transferred to other psychiatric facilities ("other hospital group"). The occurrence of suicide reattempt, readmission, administrative involuntary admission, and mortality rate associated with suicide reattempt following discharge were analyzed as prognostic factors. This study aimed to compare the prognostic factors of the two groups and evaluate their characteristics and differences. Compared with patients in the "other hospital group," those in "our hospital group" had a significantly longer length of stay and more social services, tended to live alone or in a facility following discharge, and had a significantly higher readmission rate. Furthermore, the rate of mortality caused by suicide was lower in "our hospital group" than in the "other hospital group," although not statistically significant. Our data did not reveal any differences in the prognosis of patients in both groups. However, despite the requirement for better adjustment to environmental conditions following discharge in "our hospital group," the use of social services and readmission might be effective interventions. Our findings indicated that the characteristics in "our hospital group" are probably associated with improved prognosis.
The atrioventricular (AV) annulus is a part of the fibrous skeleton of the heart and is held between the AV valve leaflet and the AV junction. This fibrous structure deteriorates over time owing to exposure to long-term pressure stress. The morphological change associated with this deterioration is known as annular disjunction; however, the initial lesion and its related changes around the AV junction are partially described. We assessed 20 autopsied adult human hearts with no major structural abnormalities (three females). The mean age was 70.8 (range: 31-88) years. After exposure to the endocardial surface of the right and left AV annuli, the annular circumferences were measured, and the ventricular summit of the AV junction was exposed by lifting the AV valve leaflets. Histological examination was performed on the perpendicular sections along the AV annulus. The mean heart weight was 330±54.2 (range: 235-400)g. No significant widening of the AV annulus circumference was observed. In the mitral annulus, small recesses assumed as initial lesions for annular disjunction were found at the anterior or posterior wall in 16 hearts (80%) and at the lateral wall in only six (30%) because of the structural support of the small trabeculation with the basal chorda. In contrast, the right ventricular summit of the AV junction was divided into three muscular patterns: 1) perpendicular to the annulus, 2) flat and fused trabeculation, and 3) parallel to the annulus. In the latter two patterns, a thin muscular layer was observed beneath the tricuspid valve attachment, regardless of age. The original structural differences between the right and left AV annuli may be the cause of morphological differences between the right and left AV annular disjunction.
A dental operating microscope (DOM) has a low degree of positioning flexibility because an eyepiece is used for observations and mirror techniques are often required for viewing the operative field. We developed a new DOM technique, termed the three-dimensional (3D) microscopic method (TMM), with a connection to a monitor that can display stereoscopic 3D images. In this study, differences in magnification characteristics obtained using TMM and a conventional microscopic method (CMM) were compared along with their effects on the precision of hand instrument usage under a magnified field of view. Five endodontists evaluated the resolution and depth of field (DOF) of the CMM and TMM using dedicated measurement targets. Furthermore, 15 dental residents used both methods to assess a target using a hand instrument, and two evaluators measured the distance between the target's center and that of the resultant hole to evaluate the effects on the precision of hand instrument usage. Resolution was significantly higher for CMM than TMM (p<0.05), although CMM had significantly lower DOFV values at Mob=0.4x (p<0.05). Furthermore, CMM had significantly lower DOFH values than TMM at Mob=0.4x and 0.6x (p<0.05), whereas TMM had significantly lower values than CMM at Mob=1.6x (p<0.05). No significant difference was observed between TMM without and CMM with the mirror technique (p>0.05). The results suggest that TMM used for magnification is less prone to differences in clinical results compared with CMM because it allows for more direct viewing while maintaining the same level of procedural accuracy.
Prior research has consistently documented elevated rates of comorbid mood and anxiety disorders in individuals with attention deficit hyperactivity disorder (ADHD). However, there remains a limited body of literature examining the manifestation of mood and anxiety symptoms in adults with ADHD who do not have comorbid mental disorders. This study aims to explore the potential vulnerability of adults with ADHD, unburdened by comorbid mental conditions, to the development of mood and anxiety disorders. We conducted a comprehensive evaluation of mood and anxiety disorder symptoms in a cohort comprising 61 adults diagnosed with ADHD, who did not exhibit comorbid mental disorders, and matched them for age and gender with 64 neurotypical control participants. This investigation involved scrutinizing the interplay between emotional symptoms and those characteristic of ADHD. Substantial disparities emerged across all symptom rating scales when comparing the ADHD group to the control group. Regarding gender distinctions within the ADHD cohort, females exhibited a heightened susceptibility, demonstrating a propensity to manifest more severe symptoms compared to their male counterparts. Notably, the ADHD group displayed more pronounced correlations among emotional symptoms and those associated with ADHD. The most marked differences between the two groups were observed in the scores of Bipolar Spectrum Diagnostic Scale (BSDS) and state anxiety assessments. The findings from this study provide compelling evidence that adults with ADHD, unencumbered by comorbid mental disorders, exhibit significantly more pronounced mood and anxiety symptoms when compared to their mentally healthy counterparts. These results underscore a noteworthy vulnerability among this population to the eventual development of mood and anxiety disorders, emphasizing the importance of targeted interventions and vigilant monitoring in clinical practice.
A modified thoracoabdominal nerve block through the perichondrial approach (M-TAPA) effectively blocks the anterior and lateral cutaneous branches of the Th5-12 thoracoabdominal nerves. A new method was devised for puncturing parallel to the costal cartilage by rotating the echo probe by 90°. This study presents two patients who underwent M-TAPA for surgical intervention: laparoscopic vaginal total hysterectomy and open adnexal resection. Case 1 involved a 49-year-old woman who underwent laparoscopic surgery and was bilaterally injected with 0.25% levobupivacaine, which successfully relieved pain and minimal postoperative complaints. Case 2 was a 38-year-old woman who underwent open adnexal resection, was bilaterally administered 0.2% levobupivacaine, and experienced effective pain management for laparotomy. Postoperative analgesia was managed with intravenous acetaminophen and fentanyl in both patients. Our approach is useful because the block was performed with a view similar to that of the existing transversus abdominis plane block under the costal arch and needle visibility was improved by placing the probe parallel to the costal cartilage. Our approach is as effective as the conventional block for lower abdominal surgery.
Despite occasional observations of sudden or unexpected deaths and deaths occurring shortly after hospitalization, studies on sudden in-hospital deaths in adults, particularly those that have been autopsied, are scarce. This study investigated 112 consecutive autopsy cases to determine the cause of death at our hospital. The cases were divided into three groups: sudden death (death within 24h of symptom onset, regardless of the duration of hospitalization; n=9), short-term death (death within 2-5 days after admission, excluding sudden death; n=24), and others (n=79). No differences were observed in age, sex, season, or time of death between the groups. The sudden-death group included the following cases: aortic dissection (n=3), acute pneumonia (n=2), asphyxia (n=2), other cause (n=1), and unknown cause (n=1). The short-term death group, on the other hand, consisted of brain disease (n=8), digestive disease (n=7), cardiovascular disease (n=6), respiratory disease (n=1), and other causes (n=2). The discordance rates between the clinical and pathological diagnoses were 22.2%, 29.2%, and 44.3% for sudden death, short-term death, and others, respectively. We found that the causes of sudden and short-term deaths were not only cardiogenic but also involved other diseases. The discordant diagnoses were aortic dissection and acute pneumonia in sudden death. Myocardial infarction was the most common cause of short-term death. To prevent sudden in-hospital deaths, not only cardiovascular diseases, such as aortic dissection and acute myocardial infarction, but also noncardiovascular ones, such as acute pneumonia, should be considered as differential diagnoses.
Intensive care unit-acquired delirium can lead to persistent cognitive dysfunction. Although it impedes independent mobilization at hospital discharge, the effects in intensive rehabilitation in the recovery phase remain unclear. An 84-year-old male was admitted to our intensive care unit with dyspnea. He was diagnosed with influenza-related pneumonia and sepsis and was placed on a mechanical ventilator for complete respiratory support. On day 14 (D14) of illness, rehabilitation was initiated. On D33, reductions in physical and cognitive functions were observed through Medical Research Council and Mini-Mental Statement Examination scores of 34 and 11 points, respectively. During his intensive care unit stay, he showed signs of delirium for 27 consecutive days. On D47, he was admitted to a postacute rehabilitation hospital where he underwent physical (strength training; basic movement, balance, and gait exercises; and endurance training), occupational (activities of daily living training), and speech (cognitive training, primarily higher-order tasks) therapies for 90 min daily. On D115, his physical function was markedly improved (Medical Research Council score, 57 points); however, his cognitive impairments persisted. On D124, he was transferred to a long-term care facility. Seamless rehabilitation from the acute to the convalescent phase was performed; however, the improvement in cognitive impairment following intensive care unit-acquired delirium was less than the improvement in physical function. Even after discharge from recovery hospitals, rehabilitation should be continued in addition to interventions in the intensive care unit aimed at preventing delirium and cognitive impairment and hastening recovery.
This cohort study examined the validity of our new classification system in predicting the difficulty level of laparoscopic cholecystectomy (LC). We enrolled consecutive patients who underwent cholecystectomy at the Division of Gastroenterological and General Surgery in Showa University Hospital, Japan. Severe-grade LC was classified according to cholecystitis severity according to the 2013 Tokyo Guidelines, preoperative imaging findings, cystic duct depiction, and anatomical anomalies of the bile duct. Cases were categorized according to the degree of difficulty as follows: E (easy), C (moderate), and D (difficult). Moreover, preoperative prediction accuracy was evaluated by determining the degree of inflammation and presence of anatomical variation based on operative data. Operative variables and morbidity were retrospectively evaluated. LC was performed in 534 patients, 424 of whom were assessed. The accuracy of the correlation between the classification system and intraoperative findings was as follows: E, 77%, C, 61%, and D, 76%. The average operative time was 109±44, 134±43, and 172±58 min for E, C, and D levels, respectively (P=0.0022; E/C, P<0.0001; C/D, P<0.0001; E/D, P=0.00017). The average blood loss was 17±31, 43±61, and 71±53ml for E, C, and D levels, respectively (P=0.0020; E/C, P<0.0001; C/D, P=0.0201; E/D, P<0.0001). The surgical outcomes significantly differed between the levels; however, the conversion and morbidity rates did not. In conclusion, our classification system was correlated with intraoperative findings and surgical outcomes, thereby contributing to improved LC outcomes.
This study aimed to investigate problems and learning curves experienced by a single surgeon performing robotic-assisted rectal surgery (RRS) for the first time. Among 62 consecutive patients who underwent RRS between May 2021 and December 2022, 30 with high anterior resection (HAR) performed by a single surgeon qualified according to the endoscopic surgical skill qualification system were retrospectively reviewed. Operative feasibility and surgical outcomes were evaluated. The cumulative sum (CUSUM) was used to visualize the learning curve of the operation time. No cases were converted to open surgery. The operative time (median, range) was 313 (163-645) min, the amount of blood loss was 5 (5-550) ml, and postoperative complications occurred in 10 (16.1%) of all 62 patients. Among 30 patients with HAR, the surgeon console time for the 10 patients in the early period was 160 (78-271) min, and that in the later period was 118 (86-234) min for 20 (P=0.03). The differences in the duration of lymph node dissection and mesorectal transection were significant between the early and later periods (P<0.01). No difference in the frequency of postoperative complications was found. RRS is a minimally invasive and safe technique even for an inexperienced surgeon according to the rectal endoscopic educational system. To shorten the learning curve, mastery of the surgical procedure of lymph node dissection and mesorectal dissection is necessary.
