MHCクラスⅡ抗体による自己免疫反応の誘導 : 閉塞性気管支疾患の免疫学的発生機序におけるマクロファージの重要性

藤田保健衛生大

Comprehensive Investigations of Multiple Factors That Are Related to Refractory Outcome in Urosepsis Patients

Background: Urosepsis is an acute life-threating disease, and some cases show refractory outcome to therapy. In an aging society of developed countries, characteristics of urosepsis are becoming complicated. We performed a comprehensive investigation regarding the clinical and social aspects that are related to refractory outcomes in urosepsis patients. Methods: The patient cohort consisted of 66 patients with urosepsis. Multiple factors from clinical and social aspects were reviewed retrospectively. Two categories of refractory outcomes were defined. One was afebrile resistance (AR); fever continued more than 7 days from the initiation of therapy. Another was discharge resistance (DR); hospitalization continued for more than 30 days. Logistic regression analyses were performed to identify significant factors that are related to the AR or DR. Results: Univariate analysis demonstrated that high score of Eastern Cooperative Oncology Group Performance Status (ECOG PS) (? 2) and Age-adjusted Charlson comorbidity index (CCI) (? 4), high serum C-reactive protein (CRP) level (? 14.9 mg/dL), and low serum albumin level (? 2.26 g/dL) were significantly related to AR. Univariate analysis results also revealed that high score of ECOG PS (? 2), high serum creatinine level (? 1.54 mg/dL) and vasopressor administration were significantly related to DR. Multivariate analyses demonstrated that low serum albumin level (? 2.26g/dL) was the only significant factor that was related to AR. In contrast, high score of ECOG PS (? 2) and high serum creatinine level (? 1.54 mg/dL) were significant factors that were related to DR. Conclusion: It is suggested that evaluating serum albumin levels is essential for the therapeutic first step because hypoalbuminemia was the significant factor that was related to obstruction to antipyresis. It is also suggested that the deterioration of patients’ activities of daily living and renal dysfunction might be the refractory factors for discharge from the hospital, which was the ultimate therapeutic goal

Low dose RAI ablation

Outpatient ablation therapy with low-dose radioactive iodine (RAI) is applied to non-low-risk papillary thyroid cancer patients due to a chronic shortage of inpatient RAI treatment wards in Japan. We used the maximum dosage available for outpatient therapy of 30 mCi of RAI for ablation and diagnostic (Dx) whole-body scintigraphy (WBS). This study aimed to examine the significance of the second dose of 30 mCi. DxWBS was performed 6 months after ablation, and assessment of success or failure was performed 12 months after ablation. A second WBS was performed in the remaining RAI accumulation cases in the neck on DxWBS. The criteria for successful ablation was negative cervical accumulation on WBS, thyroid stimulating hormone-suppressed thyroglobulin (sup-Tg) below 1.0 ng / mL, and no increase in thyroglobulin antibody (TgAb) level. At the time of DxWBS, 35 / 68 cases met the successful criteria, and 45 cases achieved success at assessment. Sup-Tg values decreased significantly after ablation and decreased further after DxWBS in successful ablation cases, whereas those were not changed in ablation failure cases. Findings indicated that RAI used in DxWBS had therapeutic effects. It makes sense to use 30 mCi for DxWBS, given the current difficulty of inpatient ablation therapy with high-dose RAI

A Comparison Between Laparoscopic and Robot-Assisted Laparoscopic Pyeloplasty in Patients with Ureteropelvic Junction Obstruction

Background: The aim of this study is to compare the results of laparoscopic pyeloplasty and robot-assisted laparoscopic pyeloplasty in patients with ureteropelvic junction obstruction. Methods: Between March 2008 and May 2019, the patients who underwent retroperitoneal laparoscopic or robotic-assisted laparoscopic pyeloplasty in our institution were retrospectively reviewed. Results: Thirteen patients underwent laparoscopically, and 12 patients underwent robotic surgery. The significant difference was found in median operative time between laparoscopic group (296 minutes) and robotic group (199 minutes) (P = 0.001). The median time for drain removal in laparoscopic group was longer than robotic group (3 vs. 2 days, respectively, P = 0.029). Conclusion: Laparoscopic and robot-assisted laparoscopic pyeloplasty is safe and excellent success rates in patients with ureteropelvic junction obstruction. However, our experience study suggested that robotic surgery improves a total operative time, decreases drain removal time and less intraoperative blood loss than laparoscopic approach

Efficacy of Combination Treatment with Tadalafil and Mirabegron in Patients with Benign Prostatic Hyperplasia Who Presented with Persistent Storage Symptoms After Tadalafil Monotreatment: A Prospective, Multicenter, Open-Labeled Study

Background: The aim of this study is to evaluate the efficacy and safety of tadalafil, a phosphodiesterase type 5 inhibitor, plus mirabegron, a β3-adrenoreceptor agonist, in patients with benign prostatic hyperplasia who presented with persistent storage symptoms after tadalafil monotreatment. Methods: The registration of this study started in August 2016 and ended in July 2019. The inclusion criteria included patients aged ? 50 years who were diagnosed with benign prostatic hyperplasia and who presented with overactive bladder symptoms. Patients were treated with oral tadalafil 5 mg once daily for 4 weeks. Then, its efficacy was evaluated. Patients who responded to the treatment received oral tadalafil 5 mg once daily for 4 more weeks (monotreatment group). Meanwhile, those who did not respond received oral tadalafil 5 mg and mirabegron 50 mg, which is an add-on treatment, once daily for 4 more weeks (combination therapy group). Results: After 8 weeks, the monotreatment group (n = 19) and the combination group (n = 56) had significantly better total Overactive Bladder Symptom Score and International Prostate Symptom Score and International Prostate Symptom Score voiding and storage subscale scores. Moreover, the two groups experienced significant improvements in the total Overactive Bladder Questionnaire and Nocturia Quality of Life Questionnaire scores, and Nocturia Quality of Life Questionnaire Bother/Concern subscale score after 8 weeks. However, there were no cases of urinary retention or serious adverse events. Conclusion: Combination treatment with tadalafil and mirabegron is effective and safe for patients with benign prostatic hyperplasia who presented with persistent storage symptoms after tadalafil monotreatment. Hence, tadalafil plus mirabegron is a promising therapeutic option, and it can improve overactive bladder related-quality of life

Experience of Cadaver Donor Nephrectomy with Cadaver Surgical Training

As cadaver donor nephrectomy in kidney transplantation is performed in only a limited number of cases, few physicians are skilled in the surgical technique. We performed two cadaver donor nephrectomy sessions during cadaver surgical training. The first session was performed by a lecturer who was skilled in the technique, with physicians and nurses participating in order to learn the methodology. The second session was conducted only for physicians. The procedures undertaken were as follows: cannulation of the femoral artery and vein, skin incision and bowel ligation, cross-clamping of the aorta, diaphragmatic incision and inferior vena cava incision, dissection of the aorta and inferior vena cava, and nephrectomy. Although there were some differences from that normally observed in actual patient surgery, such as no bleeding and formalin fixation, some of the procedures were very useful in helping to better understand cadaver donor nephrectomy

The Influence of Prior Abdominal Surgery on Robot-Assisted Partial Nephrectomy

[Background] We evaluated the influence of prior abdominal surgery on perioperative outcomes in patients who underwent robot-assisted partial nephrectomy in initial Japanese series. [Methods] We reviewed patients with small renal tumors who underwent robot-assisted partial nephrectomy from October 2011 to September 2020 at our institution. Patients with prior abdominal surgery were compared with those without prior surgery based on perioperative outcomes. The chi-square test and Mann–Whitney U test were used for statistical analyses of variables. [Results] Of 156 patients who underwent robot-assisted partial nephrectomy, 90 (58%) had no prior abdominal surgery, whereas 66 patients (42%) underwent prior abdominal surgery. No significant differences in perioperative outcomes were observed between with and without prior abdominal surgery groups. In transperitoneal approach robot-assisted partial nephrectomy, 31 patients (80.4%) had prior abdominal surgery. Trocar insertion time in the with prior abdominal surgery group took longer than the without prior abdominal surgery group (32 vs. 28.5 min, P = 0.031). No significant difference was observed in the conversion rate between the two groups (P = 0.556). [Conclusion] Robot-assisted partial nephrectomy appears to be a safe approach for patients with prior abdominal surgery. In transperitoneal approach robot-assisted partial nephrectomy with prior abdominal surgery, trocar insertion time was longer, but no significant differences were found in other outcomes. Transperitoneal approach robot-assisted partial nephrectomy is thus considered a safe procedure for patients with prior abdominal surgery

Initial Experience of Robot-Assisted Adrenalectomy in Japan: What is the Optimal Selection of Robotic Forceps for Adrenalectomy?

Minimally invasive adrenalectomy is the preferred technique for managing adrenal tumors. Laparoscopic adrenalectomy is widely performed and covered by insurance in Japan, but robot-assisted adrenalectomy is not. To investigate the best forceps combinations for performing robot-assisted adrenalectomy safely, we performed robot-assisted adrenalectomy for two left and two right adrenal adenomas using different robotic forceps combinations (bipolar forceps, monopolar curved scissors, Vessel Sealer Extend, and SynchroSeal) for each case. Although we evaluated a small number of RAs, lower blood loss was observed in patients where the vessel sealing devices were used. The extent of dissection is small for adrenalectomy, and robotic bipolar vessel sealing tools may not be necessary, especially for the small adrenal tumors. However, considering the risk benefits, the combination of forceps with Vessel Sealer Extend (by the left arm) and monopolar curved scissors (by the right arm) will become one of the best forceps combinations for performing robot-assisted adrenalectomy safely