An online lifestyle has become typical with the COVID-19 pandemic. Although the number of infected patients in Japan has decreased significantly from its peak, concern remains about the seasonality of the infection and the possibility of variant strains. In this context, 10 medical students and Dr. Shigeru Omi, Chairman of the Subcommittee on Countermeasures against Novel Coronavirus Infections, held an online panel discussion on November 6, 2021.  First, the frailty of Japan’s testing system compared to other countries was highlighted. Although weekly testing for all citizens would be ideal, implementing efficient countermeasures with limited resources was emphasized.  Second, concern exists about other diseases because people are refraining from receiving necessary medical examinations for fear of being infected with COVID-19. Strengthening mass approaches using the media and personal approaches by health care professionals is essential.  Third, much false information exists on social networking sites and is being spread. The importance of suitable individual risk communication was suggested.  Finally, medical students mentioned the loss of experience due to restrictions on school attendance and club activities. Although medical students are treated differently in each country, increasing opportunities to discuss the purpose of medical education and whether online alternatives are possible were highlighted.  This was the first opportunity for a direct discussion between medical students, who have been greatly affected by COVID-19, and Dr. Omi, a policymaker. We hope that more such discussions will be possible, and that people’s opinions will be considered toward a better environment.

Objective: Direct oral anticoagulants (DOACs) are increasingly being used for the treatment of cancer-associated venous thromboembolism (CAT). However, there is limited evidence of the efficacy of DOACs for the treatment of gynecological CAT. Thus, this study aimed to investigate the efficacy and safety of edoxaban for the treatment of gynecological CAT using Japanese real-world data. Methods: We reviewed the medical records of patients with 371 gynecological cancer who received edoxaban or vitamin K antagonist (VKA) between January 2011 and December 2018. Results: Altogether, 211 and 160 patients were treated with edoxaban and VKA, respectively. Fourteen patients (6.8%) in the edoxaban group and 22 (13.8%) in the VKA group showed recurrence of venous thromboembolism (VTE). Cumulative VTE recurrence was not significantly different between the 2 groups (p=0.340). Adverse events occurred in 15 (7.1%) and 11 (6.9%) patients in the edoxaban and VKA groups, respectively (p=0.697). Subgroup analysis of the edoxaban and VKA groups according to different tumor types, including ovarian, endometrial, and cervical cancer, showed equivalent outcomes in terms of VTE recurrence and adverse events. Patients without pulmonary embolism (PE) were mostly omitted from initial unfractionated heparin (UFH) therapy prior to administration of edoxaban. However, this did not increase the recurrence of VTE. Conclusion This study confirmed that edoxaban is effective and safe for the treatment of gynecological CAT. This finding was consistent for different types of gynecological cancer. Additionally, initial UFH therapy prior to the administration of edoxaban may be unnecessary for patients without PE.

BACKGROUND/AIMS: We recently identified recessive mutations in the solute carrier organic anion transporter family member 2A1 gene (SLCO2A1) as causative variants of chronic nonspecific multiple ulcers of the small intestine (chronic enteropathy associated with SLCO2A1, CEAS). The aim of this study was to investigate the gastroduodenal expression of the SLCO2A1 protein in patients with CEAS and Crohn’s disease (CD). METHODS: Immunohistochemical staining for SLCO2A1 was performed with a polyclonal antibody, HPA013742, on gastroduodenal tissues obtained by endoscopic biopsy from four patients with CEAS and 29 patients with CD. RESULTS: The expression of SLCO2A1 was observed in one of four patients (25%) with CEAS and in all 29 patients (100%) with CD (p < 0.001). The three patients with CEAS without SLCO2A1 expression had a homozygous splice-site mutation in SLCO2A1, c.1461+1G>C (exon 7) or c.940+1G>A (exon 10). The remaining one CEAS patient with positive expression of SLCO2A1 had compound heterozygous c.664G>A and c.1807C>T mutations. CONCLUSIONS: Immunohistochemical staining for SLCO2A1 in gastroduodenal tissues obtained by endoscopic biopsy is considered useful for the distinction of CEAS from CD.
Biopsy ; Crohn Disease* ; Humans ; Immunohistochemistry ; Intestine, Small ; Ulcer

OBJECTIVE: Our objective was to determine the feasibility and detection rates and clarify the most effective combination of injected tracer types for sentinel lymph node (SLN) mapping in uterine cervical cancer in patients who have undergone laparoscopic surgery or neoadjuvant chemotherapy (NAC). METHODS: A total of 119 patients with cervical cancer underwent SLN biopsy at radical hysterectomy using three types of tracers. The various factors related to side-specific detection rate, sensitivity, and false negative (FN) rate were analyzed. RESULTS: The SLN detection rates using 99m-technetium ((99m)Tc)-tin colloid, indigo carmine, and indocyanine green (ICG) were 85.8%, 20.2%, and 61.6%, respectively. The patients with ≥2-cm-diameter tumors and those who received NAC had lower detection rates than those with <2-cm-diameter tumors (75.7% vs. 91.5%, p<0.01) and those who did not receive NAC (67.9% vs. 86.3%, p<0.01), respectively. Laparoscopic procedures had a higher detection rate than laparotomy (100.0% vs. 77.1%, p<0.01). No factors significantly affected the sensitivity; however, the patients with ≥2-cm-diameter tumors (86.0% vs. 1.4%, p<0.01), NAC (19.4% vs. 2.2%, p<0.01), and those who underwent laparotomy (7.4% vs. 0%, p<0.01) had an unfavorable FN rate. CONCLUSION: Among the examined tracers, (99m)Tc had the highest detection of SLN mapping in patients with uterine cervical cancer. Patients with local advanced cervical cancer with/without NAC treatment might be unsuited for SLN mapping. SLN mapping is feasible and results in an excellent detection rate in patients with <2-cm-diameter cervical cancer. Laparoscopic surgery is the best procedure for SLN detection in patients with early-stage disease.
Biopsy ; Colloids* ; Drug Therapy ; Humans ; Hysterectomy ; Indigo Carmine ; Indocyanine Green* ; Laparoscopy* ; Laparotomy ; Lymph Nodes* ; Uterine Cervical Neoplasms*

Treatment of perianal and vulvar extramammary Paget disease (EMPD), rare intraepithelial malignancies, is often challenging because of its potential to spread into the anal canal. However, there is still no consensus regarding the optimal resection margin within the anal canal. Between 2004 and 2014, six patients (three with perianal EMPD and three with vulvar EMPD) in which the spread of Paget cells into the anal canal was highly suspected were referred to our department. To evaluate the disease extent within the anal canal, preoperative mapping biopsy of the anal canal was performed in five out of six patients. Two patients were positive for Paget cells within the anal canal (one at the dentate line and the other at 0.5 cm above the dentate line), whereas in three patients, Paget cell were present only in the skin of the anal verge. Using 1 cm margin within the anal canal from the positive biopsy sites, we performed anal-preserving wide local excision (WLE), and negative resection margins within the anal canal were confirmed in all five patients. The remaining one patient with perianal EMPD did not undergo mapping biopsy of the anal canal because preoperative colonoscopy revealed that the Paget cells had spread into the lower rectum. Therefore, WLE with abdominoperineal resection was performed. During the median follow-up period of 37.3 months, no local recurrence was observed in all patients. Our small case series suggest the usefulness of mapping biopsy of the anal canal for the treatment of perianal and vulvar EMPD.
Anal Canal* ; Biopsy* ; Colonoscopy ; Consensus ; Follow-Up Studies ; Humans ; Paget Disease, Extramammary* ; Rectum ; Recurrence ; Skin

Treatment of perianal and vulvar extramammary Paget disease (EMPD), rare intraepithelial malignancies, is often challenging because of its potential to spread into the anal canal. However, there is still no consensus regarding the optimal resection margin within the anal canal. Between 2004 and 2014, six patients (three with perianal EMPD and three with vulvar EMPD) in which the spread of Paget cells into the anal canal was highly suspected were referred to our department. To evaluate the disease extent within the anal canal, preoperative mapping biopsy of the anal canal was performed in five out of six patients. Two patients were positive for Paget cells within the anal canal (one at the dentate line and the other at 0.5 cm above the dentate line), whereas in three patients, Paget cell were present only in the skin of the anal verge. Using 1 cm margin within the anal canal from the positive biopsy sites, we performed anal-preserving wide local excision (WLE), and negative resection margins within the anal canal were confirmed in all five patients. The remaining one patient with perianal EMPD did not undergo mapping biopsy of the anal canal because preoperative colonoscopy revealed that the Paget cells had spread into the lower rectum. Therefore, WLE with abdominoperineal resection was performed. During the median follow-up period of 37.3 months, no local recurrence was observed in all patients. Our small case series suggest the usefulness of mapping biopsy of the anal canal for the treatment of perianal and vulvar EMPD.
Anal Canal* ; Biopsy* ; Colonoscopy ; Consensus ; Follow-Up Studies ; Humans ; Paget Disease, Extramammary* ; Rectum ; Recurrence ; Skin

Infectious abdominal aortic aneurysm is a relatively rare disease, and there is no consensus regarding its surgical treatment. Medical infectious control should be concerned comparison with surgical treatment if there is sepsis, however we sometimes have no other choice but emergency operation for uncontrollable cases. In many reports, cryopreserved homografts were used as in-situ alternative grafts for infectious aortic aneurysms because they had some merits such as anti-infectious effects, suitability and so on. However the number of in-situ cryopreserved homograft replacement cases are few, and the long term result is unclear. We encountered a ruptured cropreserved homograft case 7 months after urgent in-situ cryopreserved homograft replacement. We report the case and refer to the relevans literature.

This study investigated the effects of exercise intervention with a 12-week slightly-weighted shoe on lower-limb skeletal muscle and gait patterns in the elderly. A total of 29 healthy elderly Japanese who had irregular walking habits were randomly assigned to either slightly-weighted-shoe (WS group, n = 14; Age, 70.6 ± 5.7 years; WS, 493 g) or normal-shoe (NS group, n = 15; Age, 69.3 ± 6.9 years; NS, 293 g) intervention groups. The participants were instructed to maintain their normal daily physical activity (PA) during the intervention period. Segmental intracellular water (ICW) and muscle thickness (MT) were measured as an index of skeletal muscle mass in the lower limb, and kinematic gait data were acquired by motion analysis. Walking stability was assessed as a standard deviation of the vertical fluctuation in whole-body center of mass (COM fluctuation). The daily PA was monitored using an accelerometer and an activity record. ICW in the upper leg and MT of rectus femoris increased significantly in the WS group compared with the NS group (ICW: 13.8% vs. 2.2%, MT: 12.1% vs. 1.3%), while COM fluctuation was significantly reduced in the WS group (p<0.05) during normal walking. The present study demonstrated that interventions with a slightly-weighted-shoe may be able to increase muscle volume in the upper leg and change gait patterns in the healthy elderly.

We encountered three cases of infra-renal infected abdominal aortic aneurysm in 2007 and 2008. Preoperative blood culture was positive in two of the three patients. All of the patients presented with fever of unknown origin. We replaced the affected segment of the abdominal aorta with a synthetic graft in 1 patient, and with a cryopreserved arterial homograft in the remaining 2 patients. An infected abdominal aortic aneurysm is a life-threatening condition. Diagnosis is often difficult, and emergency surgery may be necessitated by rupture of the aneurysm. Our experience suggests that computed tomography is effective for the diagnosis of infected aneurysms. The most effective surgical technique consists of complete resection of the aneurysm, in-situ replacement of the affected aortic segment with a synthetic graft or homograft, and omental coverage.

[Purpose]Acupuncture stimulation is known to improve visual acuity. Since this improvement was frequently disassociated with refractive change, we determined the mechanism by examining the patients without lens accommodation.
[Methods]Patients (n = 30) receiving cataract surgery in 2005 at Meiji University of Oriental Medicine Hospital were examined (mean age: 73.0). Bilateral LI4, Taiyang and shang-jingming points were stimulated by acupuncture needles for 10 min (acupoints stimulation). On a different day, the same patients received sham points stimulation at 1 cm above or lateral from the above-mentioned acupoints. Both uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA) was measured with a logMAR scale at pre-and post-acupuncture stimulations. Furthermore, the patients with improved UCVA and BCVA typically (n = 4) received topical tropicamide eyedrops for suppression of pupil diameter change. UCVA and BCVA were measured at pre-and post-acupuncture stimulation.
[Results]Acupoints stimulation significantly improved both UCVA (0.39 to 0.30, p < 0.0006) and BCVA (0.15 to 0.08, p < 0.0001). Although sham points stimulation also significantly improved both UCVA (0.38 to 0.32, p < 0.02) and BCVA (0.14 to 0.09, p < 0.0001), there was no significant difference in comparison with acupoints stimulation controls. Under mydriasis after tropicamide eyedrops, acupuncture stimulation did not improved UCVA, and the variation of BCVA was significantly different from control (p < 0.013).
[Discussion]Acupuncture stimulation improved UCVA and BCVA even in elderly patients that lack accommodation. Our results imply that as pupil diameter changes, a subsequent pinhole effect may be a critical mechanism for UCVA and BCVA improvement by acupuncture stimulation. In addition, the phenomena are not specific effects of acupoints and imply a response via sensory nerves.