Purpose: The proportion of terminally ill cancer patients who were discharged home from a hospice/palliative care unit and subsequently died either at home or in the palliative care unit, whose final place of death was consistent with their intended place of care, remains unclear. This study aimed to clarify the consistency between the preferred and actual place of death. Methods: This study was a supplementary study to a multi-institutional bereavement survey conducted in 2018. Results: Responses were obtained from the bereaved families of 202 patients who died at home and 157 patients who died in a palliative care unit. Among them, 80% of home deaths and 82% of palliative care unit deaths were consistent with the stated end-of-life care preference. Among the 22 cases who preferred to die in a palliative care unit but died at home, the most common reason was the availability of physicians and nurses who could provide end-of-life care at home. Among the 11 cases who preferred to die at home but the patients died in a palliative care unit, the most common reason was insufficient pain management at home. Conclusion: Approximately 80% of patients died by their end-of-life care preference, suggesting that many were able to die in their preferred location.

The nasal mucosa and submucosa likely contain both vascular beds against cold and dry air and resident immunoreactive cells against various antigens. Therefore, a specific fibrous structure seems to be necessary. Using histological specimens from 20 elderly cadavers, we examined the nasal mucosal and submucosal architecture. The ciliated columnar epithelium of the nasal mucosa was characterized by 1) a thick basal lamina, 2) few elastin-positive fibers beneath the epithelium, that was quite different from the nearby mucocutaneous junction area with a thick layer (0.3–0.8 mm) of elastic and oxytalan fibers corresponding to the skin dermis, 3) CD34-positive cells distributing diffusely in the submucosal tissue, and 4) few smooth muscle actin (SMA)-positive fibers beneath the epithelium. Some of submucosal fibrous structure appeared to express both elastin and CD34. CD34-positive arterioles were abundant beneath the ciliated epithelium, but they appeared negative for SMA antibody that cross-reacts with endothelium. Notably, the ciliated columnar epithelium was thin in the lateral wall of the nasal cavity, while the inferior concha carried the thick pseudostratified columnar epithelium.Strangely, the inferior or palatal wall of the nasal cavity was covered by the thick stratified epithelium. We found SMApositive mucosal venous plexus in the lateral wall of nasal cavity, but the submucosa was filled with glands in the inferior concha. Vascular beds might be replaced by glands in the nasal submucosa. The site-dependent difference in the mucosal morphology as well as the absence of vascular beds might be a result of secondary change with aging.

Background: Identifying dysmorphic red blood cells (RBCs) is critical for diagnosing glomerular diseases, as distinguishing glomerular from non-glomerular hematuria may reduce reliance on invasive diagnostics such as kidney biopsy. We aimed to enhance urinary RBC morphological classification by employing machine learning (ML) to analyze UF-5000 scattergram data. Methods: RBCs in urine samples (N = 185) were classified as dysmorphic or isomorphic based on microscopic findings. UF-5000 scattergrams were quantified to generate 20 statistical features and used to train a ML model in DataRobot (v9.1) with an automated pipeline, five-fold cross-validation, and LogLoss-based selection. Performance was evaluated in an independent cohort (N = 1,093). Accuracy was defined as concordance with microscopy findings. Areas under ROC curves (AUROCs) and diagnostic metrics are reported with 95% confidence intervals (CIs). Results: Among conventional UF-5000 parameters, the small RBC/total RBC ratio was the strongest predictor (AUROC 0.97, 95% CI 0.94–0.99). Scattergram-derived features indicated that RBC size-related parameters were crucial for identifying dysmorphic RBCs. The ML model alone demonstrated superior accuracy over UF-5000 RBC-Info alone (concordance 95.2% vs. 92.1%; AUROC 0.95 [0.94–0.97] vs. 0.92 [0.91–0.94]). Logical (OR/ AND) combinations of the ML model with RBC-Info outperformed RBC-Info alone (OR: concordance 92.7%, AUROC 0.93 [0.92–0.95]; AND: concordance 94.6%, AUROC 0.94 [0.93–0.96]). Conclusions A scattergram-based ML model improves the accuracy and reliability of urinary RBC morphological classification based on UF-5000 scattergrams and may help reduce reliance on invasive diagnostics. Prospective, multicenter studies should validate generalizability and assess integration into routine workflows.

Tumor necrosis factor receptor-associated factor 3 (TRAF3) is an anti-inflammatory molecule that negatively regulates the non-canonical nuclear factor-κB pathway. Although TRAF3 haploinsufficiency (TRAF3 HI) can influence innate and adaptive immune cells, its effect on inflammatory bowel disease (IBD) development remains unclear. Here, we report the first case of severe early-onset IBD with a novel TRAF3 variant leading to HI, successfully treated with ustekinumab. A 6-year-old girl with a recurrent parotitis, otitis media, tonsilitis, and atopic dermatitis developed IBD involving the stomach, small intestine, and colon. At diagnosis, the immunoglobulin (Ig)G and IgA levels were relatively high, and lymphocyte subsets showed increased counts of plasmablasts, class-switch recombination B cells, and circulating T-follicular helper cells. Treatment with azathioprine and infliximab failed to maintain remission marked by several relapses accompanied by erythema nodosum and arthritis; however, ustekinumab, an anti-interleukin (IL)-12/23p40 antibody, led to long-term clinical remission, normalizing the Ig level and reducing abnormal lymphocyte counts. Whole-exome sequencing revealed a novel heterozygous mutation in TRAF3 [p.(Pro487Leufs*8)], resulting in TRAF3 under-expression. Our case may highlight the contribution of TRAF3 HI to the development of IBD and provide insights into IBD pathophysiology, suggesting the involvement of the IL-12/23-T-follicular helper cell pathway affected by genetic mutations.

Objective: This multicenter study aimed to evaluate the impact of paravertebral muscles (PVMs) degeneration, particularly fat infiltration, on preoperative sagittal imbalance, and postoperative complications and sagittal alignment change in patients with adult spinal deformity (ASD). Methods: A retrospective analysis was conducted on 454 patients who underwent ASD surgery across 5 institutions. Patients were classified into 2 groups based on paraspinal muscle fat infiltration on MRI: those with significant infiltration (FI-PVM(+)) and those with minimal or no infiltration (FI-PVM(-)). Propensity score matching was performed to adjust for demographic factors and preoperative radiographical parameters. Spinopelvic parameters were assessed preoperatively, postoperatively, and at a 2-year follow-up. Mechanical complications were compared between the groups. Results: The FI-PVM(+) group showed greater sagittal vertical axis (86.4 ± 57.5 vs. 51.8 ± 59.2, p < 0.001) preoperatively and required more extensive surgical correction with a significantly greater number of fused vertebral levels (7.3 ± 3.7 vs. 6.7 ± 3.7, p < 0.039). After propensity score matching, both groups showed significant improvement in spinopelvic alignment postoperatively, maintained throughout the 2-year follow-up. However, the FI-PVM(+) group demonstrated a trend toward a higher incidence of distal junctional kyphosis (6.3% vs. 0.9%, p = 0.070) and exhibited significantly greater decrease in pelvic tilt postoperatively (4.3° ± 7.6° vs. 1.3° ± 8.2°, p = 0.006). Conclusion Fat infiltration in PVM is associated with increased surgical complexity and a higher risk of mechanical complications. Preoperative assessment of muscle quality, along with targeted rehabilitation and closer postoperative monitoring, may be crucial for improving long-term outcomes in ASD surgery.

Objective: This multicenter study aimed to evaluate the impact of paravertebral muscles (PVMs) degeneration, particularly fat infiltration, on preoperative sagittal imbalance, and postoperative complications and sagittal alignment change in patients with adult spinal deformity (ASD). Methods: A retrospective analysis was conducted on 454 patients who underwent ASD surgery across 5 institutions. Patients were classified into 2 groups based on paraspinal muscle fat infiltration on MRI: those with significant infiltration (FI-PVM(+)) and those with minimal or no infiltration (FI-PVM(-)). Propensity score matching was performed to adjust for demographic factors and preoperative radiographical parameters. Spinopelvic parameters were assessed preoperatively, postoperatively, and at a 2-year follow-up. Mechanical complications were compared between the groups. Results: The FI-PVM(+) group showed greater sagittal vertical axis (86.4 ± 57.5 vs. 51.8 ± 59.2, p < 0.001) preoperatively and required more extensive surgical correction with a significantly greater number of fused vertebral levels (7.3 ± 3.7 vs. 6.7 ± 3.7, p < 0.039). After propensity score matching, both groups showed significant improvement in spinopelvic alignment postoperatively, maintained throughout the 2-year follow-up. However, the FI-PVM(+) group demonstrated a trend toward a higher incidence of distal junctional kyphosis (6.3% vs. 0.9%, p = 0.070) and exhibited significantly greater decrease in pelvic tilt postoperatively (4.3° ± 7.6° vs. 1.3° ± 8.2°, p = 0.006). Conclusion Fat infiltration in PVM is associated with increased surgical complexity and a higher risk of mechanical complications. Preoperative assessment of muscle quality, along with targeted rehabilitation and closer postoperative monitoring, may be crucial for improving long-term outcomes in ASD surgery.

Background/Aims: Visualization of palisade vessels (PVs) in Barrett’s esophagus is crucial for proper assessment. This study aimed to determine whether red dichromatic imaging (RDI) improves PV visibility compared with white-light imaging (WLI) and narrow-band imaging (NBI). Methods: Five expert and trainee endoscopists evaluated the PV visibility in Barrett’s esophagus using WLI, NBI, and RDI on 66 images from 22 patients. Visibility was rated on a 4-point scale: 4, excellent; 3, good; 2, fair; and 1, poor. The color difference between the most recognizable PV spots and surrounding areas with undetectable blood vessels was also analyzed. Results: Mean visibility scores were 2.6±0.7, 2.3±0.6, and 3.4±0.4 for WLI, NBI, and RDI, respectively. The RDI scores were significantly higher than the WLI (p<0.001) and NBI (p<0.001) scores. These differences were recognized by trainees and expert endoscopists. Color differences in PVs were 7.74±4.96 (WLI), 10.43±5.09 (NBI), and 15.1±6.54 (RDI). The difference in RDI was significantly higher than that in WLI (p<0.001) and NBI (p=0.006). Conclusions RDI significantly improved PV visibility compared to WLI and NBI based on objective and subjective measures.

Background/Aims: Visualization of palisade vessels (PVs) in Barrett’s esophagus is crucial for proper assessment. This study aimed to determine whether red dichromatic imaging (RDI) improves PV visibility compared with white-light imaging (WLI) and narrow-band imaging (NBI). Methods: Five expert and trainee endoscopists evaluated the PV visibility in Barrett’s esophagus using WLI, NBI, and RDI on 66 images from 22 patients. Visibility was rated on a 4-point scale: 4, excellent; 3, good; 2, fair; and 1, poor. The color difference between the most recognizable PV spots and surrounding areas with undetectable blood vessels was also analyzed. Results: Mean visibility scores were 2.6±0.7, 2.3±0.6, and 3.4±0.4 for WLI, NBI, and RDI, respectively. The RDI scores were significantly higher than the WLI (p<0.001) and NBI (p<0.001) scores. These differences were recognized by trainees and expert endoscopists. Color differences in PVs were 7.74±4.96 (WLI), 10.43±5.09 (NBI), and 15.1±6.54 (RDI). The difference in RDI was significantly higher than that in WLI (p<0.001) and NBI (p=0.006). Conclusions RDI significantly improved PV visibility compared to WLI and NBI based on objective and subjective measures.

The patient is a 66-year-old woman. She had been taking steroids for some years for rheumatoid arthritis and had been using crutches for some years because of multiple joint deformities. She presented herself to an orthopedic clinic for right upper extremity numbness and was diagnosed with cervical spondylosis and was kept under observation. However, 7 days later, a pulsatile mass on her right upper arm was found and she was referred to our hospital. Contrast-enhanced CT revealed a right brachial artery aneurysm (19×17×16 mm）, and the numbness was considered to be a symptom of nerve compression caused by the aneurysm. Since the cause of the brachial artery aneurysm was long-term inappropriate use of crutches, we confirmed that the patient would not use crutches and would use other assistive devices after the surgery, and then performed aneurysm resection and direct anastomosis under general anesthesia. Aneurysms of the upper extremities are rare and are often traumatic or iatrogenic pseudoaneurysms, and surgery is recommended because they can cause complications such as embolism, nerve compression, and rupture. In revascularization in cases where the aneurysm is caused by crutches, it is necessary to consider the risk of recurrence. In our case, we were able to perform direct anastomosis by switching the walking aid from crutches to Lofstrand clutches.

Objective: This multicenter study aimed to evaluate the impact of paravertebral muscles (PVMs) degeneration, particularly fat infiltration, on preoperative sagittal imbalance, and postoperative complications and sagittal alignment change in patients with adult spinal deformity (ASD). Methods: A retrospective analysis was conducted on 454 patients who underwent ASD surgery across 5 institutions. Patients were classified into 2 groups based on paraspinal muscle fat infiltration on MRI: those with significant infiltration (FI-PVM(+)) and those with minimal or no infiltration (FI-PVM(-)). Propensity score matching was performed to adjust for demographic factors and preoperative radiographical parameters. Spinopelvic parameters were assessed preoperatively, postoperatively, and at a 2-year follow-up. Mechanical complications were compared between the groups. Results: The FI-PVM(+) group showed greater sagittal vertical axis (86.4 ± 57.5 vs. 51.8 ± 59.2, p < 0.001) preoperatively and required more extensive surgical correction with a significantly greater number of fused vertebral levels (7.3 ± 3.7 vs. 6.7 ± 3.7, p < 0.039). After propensity score matching, both groups showed significant improvement in spinopelvic alignment postoperatively, maintained throughout the 2-year follow-up. However, the FI-PVM(+) group demonstrated a trend toward a higher incidence of distal junctional kyphosis (6.3% vs. 0.9%, p = 0.070) and exhibited significantly greater decrease in pelvic tilt postoperatively (4.3° ± 7.6° vs. 1.3° ± 8.2°, p = 0.006). Conclusion Fat infiltration in PVM is associated with increased surgical complexity and a higher risk of mechanical complications. Preoperative assessment of muscle quality, along with targeted rehabilitation and closer postoperative monitoring, may be crucial for improving long-term outcomes in ASD surgery.