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Background: There have been relatively many reports of cases of acute hydrops followed by infectious keratitis, there has not been a report of cases of infectious keratitis complicated by acute hydrops. Case presentation: A 35-year-old man had undergone cataract surgery 7 years earlier and was being treated for atopic dermatitis by a neighborhood dermatologist. However, the dermatitis was poorly controlled. He came to our hospital with a complaint of pain and blurred vision in his left eye. The decimal best-correctly visual acuity (BCVA) of the left eye was 0.01. Slit-lamp microscopy showed conjunctival injection and a corneal opacity. The patient was diagnosed with infectious keratitis and treated with topical and systemic antibiotics. During his hospitalization, we noted that he frequently rubbed his eyes vigorously. Five days after the first visit, the cornea was noted to protrude markedly and the stroma surrounding an ulcerated area was edematous. These findings led to the diagnosis of acute hydrops and he underwent keratoplasty for the impending corneal perforation. Histopathological study of the excised cornea showed stromal edema, leucocyte infiltration, and a tear of Descemet membrane. Unfortunately, he developed endophthalmitis on the day after the surgery. We irrigated the anterior chamber with antibiotics and injected antibiotics into the vitreous. The endophthalmitis gradually subsided, and at two years after the surgery, his decimal BCVA had improved to 0.6. Conclusions: Eye rubbing in cases of infectious keratitis can induce acute hydrops and timely surgical intervention is recommended.

Purpose: To report our findings in a case of pellucid marginal corneal degeneration (PMCD) in the left eye and keratoconus (KC) in the right eye, and to review earlier cases of PMCD and KC. Observations: A 45-year-old woman visited our hospital with a complaint of reduced vision in her right eye. She was predisposed to allergies since childhood and had a habit of rubbing her eyes. Based on the results of the corneal topographic study, we diagnosed her with KC in the right eye and PMCD in the left eye. We prescribed a rigid, gas permeable contact lens and treated her allergic conjunctivitis with ocular medications. Three years after her initial visit, she developed a corneal perforation in the left eye. The perforation was closed by conservative treatment consisting of therapeutic soft contact lens wear. One year after the cornea healed, the corneal astigmatism in the left eye was about one-half of what it was before the corneal perforation. Her corrected visual acuity improved to 1.0 with conventional spectacles. Conclusionand Importance: We found a difference in the progression of KC and PMCD even when they occurred in same individual. We suggest that the atopic predisposition, which is considered a risk factor for acute hydrops in KC, to be a risk factor for acute hydrops and corneal perforation in eyes with PMCD.

Background Stoma-related complications are not rare, whereas the spontaneous perforation of the stoma limb is relatively rare. Herein, we report a case of stoma limb perforation which occurred after Hartmann’s operation. Case presentation A 50-year-old Japanese man presented to our Hospital with acute and severe abdominal pain. Abdominal computed tomography (CT) scan revealed that an abscess with free air was formed around the sigmoid colon. We performed Hartmann’s operation, whereas he experienced redness, purulent discharge, and swelling around the colostomy at 10 days postoperatively. The contrast-enhanced CT scan of the abdomen revealed an abscess formation with air around the colostomy. He was diagnosed with an abdominal wall abscess due to perforation of the stoma limb. After the drainage, his symptoms were ameliorated by oral analgesics, anti-inflammatory drugs, and prophylactic antibiotic. Four months after the first operation, we performed a closedown of the sigmoid colostomy and fistula resection. The patient’s postoperative course was uneventful, and he was discharged 14 days later. Conclusions This case depicts rare complications of Hartmann’s operation. Operation is usually performed in patients with stoma limb perforation. However, if they are stable and the abscess is located in their abdominal wall, they may be treated successfully using a multi-stage approach of local drainage toward the stoma wall followed by stoma closure.

Background Torsion of the greater omentum is a rare cause of acute abdominal pain in adults and children. It is very difficult to make a correct diagnosis of torsion clinically because it mimics other acute pathologies; however, the preoperative diagnosis can be easily confirmed with the use of computed tomography (CT). Herein, we report a case of laparoscopic omentectomy for primary torsion of the omentum, which was not improved by conservative treatment. Case presentation A 50-year-old Japanese man presented to our hospital with acute right lower quadrant abdominal pain of a few hours’ duration. Routine blood tests showed a white blood cell count of 8900/mm3, and the C-reactive protein (CRP) level was 8.13 mg/dl. Contrast-enhanced CT scan of the abdomen revealed twisting of the omentum with a local mass of fat density and fluid distributed in a whirling oval-shaped mass pattern at the right flank and iliac fossa. Therefore, the patient was admitted to our hospital based on a diagnosis of omental torsion. The patient was treated with conservative treatment with analgesics, anti-inflammatories, and antibiotics. Although his symptoms were ameliorated, his laboratory and radiological findings worsened. We performed laparoscopic omentectomy 6 days after admission. The resected omentum was 24 cm × 22 cm in size and was twisted and dark red in color, suggesting infarction. Histological analysis revealed that the specimen was ischemic and hemorrhagic omentum, accompanied by inflammatory infiltration. The patient’s postoperative course was uneventful, and he was discharged 9 days later. Conclusion This is a rare case of primary torsion of the greater omentum that was treated successfully with laparoscopic omentectomy. Considering the increase in surgical difficulty due to inflammation from prolonged torsion and the limited efficacy of conservative treatment, we conclude that surgical intervention is warranted as early as possible when torsion of the greater omentum is suspected.

The use of surgical treatment for refractory isolated gastric varices has decreased owing to the development of endoscopic and radiologic procedures, although surgeries are sometimes required as the final method. A 75-year-old Japanese woman was diagnosed with solitary gastric varices. Initially, intraoperative splenic artery embolization was performed using the balloon transcatheter technique under general anesthesia. Laparoscopic splenectomy was performed safely owing to preoperative splenic artery embolization. Intraoperative indocyanine green (ICG) fluorescence angiography was performed following the injection of 5 mL of ICG; the remnant stomach was observed using laparoscopic equipment with an ICG imaging system, and blood flow from the remnant gastric artery was confirmed. The blood did not pool or wash out immediately, which confirmed successful devascularization of the stomach. The total operative time was 269 minutes, and the intraoperative blood loss was 500 mL. The patient’s postoperative course was good, and at 21 days after the last operation, she was discharged from our hospital in remission. Real-time fluorescence angiography with ICG is a reliable and objective technique of assessing blood flow of the stomach. Accurate, extensive devascularization in the lower esophagus and upper stomach was performed using Hassab’s procedure in combination with ICG imaging.

Owing to the advantages of a laparoscopic approach, laparoscopic cholecystectomy (LC) is thought to be the treatment of choice in gallbladder disease, even in cases of suspected malignancy. However, it is difficult to differentiate between cholecystitis and gallbladder carcinoma (GBC). We performed radical hepatectomy in patients with pT2 GBC diagnosed by full-thickness frozen biopsy. A 75-year-old Japanese man presented to our hospital with discomfort in the right upper quadrant of the abdomen. This patient was diagnosed with suspected GBC and was scheduled to undergo LC and intraoperative histological examination. Following the procedure, we made a diagnosis of GBC with negative invasion of the cystic duct stump. We converted the laparoscopic procedure to an open surgery involving wedge liver resection with lymphadenectomy. The patient was discharged from our hospital in remission 14 days following the radical hepatectomy. Histological examination showed that the GBC had invaded the liver (T3a), but there was no lymph node metastasis (N0): stage IIIA. Between April 2009 and September 2018, 580 patients underwent cholecystectomy for gallbladder disease at our hospital. Among these, 8 (1.4%) were suspected to have GBC preoperatively and underwent laparoscopic excisional cholecystectomy. We performed elective surgery in the early stage in two patients and second-look surgery in two patients recently. We were able to perform what we termed a laparoscopic excisional cholecystectomy, involving LC with a full-thickness frozen biopsy, even in situations where intraoperative histological examination was not available. Altogether, laparoscopic excisional cholecystectomy is an effective surgical treatment for suspected early GBC.

Purpose This paper presents an overview of the surgical strategy for patients with suspected gallbladder carcinoma (GBC), including incidental GBC cases, preoperatively or intraoperatively, as well as their outcomes. Methods Between April 2009 and December 2017, 529 patients underwent cholecystectomy for gallbladder disease at our hospital. Both intraoperative and postoperative histological examinations of the excised gallbladder facilitated the diagnosis of GBC. Surgery-related variables and surgical approaches were evaluated according to the extent of tumor invasion. Results Of 529 patients, eight were diagnosed with GBC during/after cholecystectomy, including four women and four men. Mean age was 75.4 (range, 59–89) years. Five patients had gallbladder stones and three had cholecystitis. Three patients with stages T1b and T2 underwent additional liver bed wedge resections with or without prophylactic common bile duct excision. Five of the eight patients are still alive and two of the remaining three died from other diseases; one patient with pT3 died of recurrent GBC (peritonitis carcinomatosa). Conclusion Because of the ability to obtain full-thickness frozen biopsies during laparoscopic cholecystectomy, we could diagnose GBC intraoperatively, allowing for rapid diagnosis and tumor resection. We recommend developing a surgical treatment strategy for suspected early GBC in advance of cholecystectomy., Highlights • Gallbladder carcinoma can be diagnosed during or after cholecystectomy. • Frozen biopsies from cholecystectomy allow for the intraoperative diagnosis of GBC. • The intraoperative diagnosis of GBC facilitates surgical resection of tumors. • Surgical strategies incorporating intraoperative diagnosis should be developed.

本研究の目的は、オストメイトおよび家族の困難を乗り越えるプロセスに機能する力（レジリエンス）の因子構造、及びレジリエンスに影響する要因を明らかにすることである。オストメイトと家族を対象に郵送法による質問紙調査を行った。回答のあったオストメイト164 名、家族104 名を分析対象とし、レジリエンス項目について因子分析を行った結果、オストメイトのレジリエンスが4 因子、家族のレジリエンスが3 因子で構成された。オストメイトは、家族の『問題解決力』、『支援認知力』、『前進的思考力』のうち『支援認知力』が『家族・社会支援認知力』と『医療者支援認知力』の別因子で抽出された。信頼性、妥当性の検討を行い、尺度として使用できることを確認した。重回帰分析の結果、オストメイトのレジリエンスはストーマ管理を自分で行っていること、家族のレジリエンスはオストメイトにかかわっていることが影響していると考えられた。

本研究は、口唇裂・口蓋裂（以後CLP とする）児の専門医療機関での経験豊かな看護師11名のCLP 児の母親に対す る看護援助の内容と援助する上で感じている問題を明らかにすることを目的とした。看護援助は、【専門医療機関内での看護援助の実際】と【出向での看護の実際】に、援助する上での問題は【看護実践 の基盤】と【専門医療機関での問題意識と対応】のコアカテゴリーが抽出できた。本論文では、主に【専門医療機関内 での看護援助の実際】除くコアカテゴリーの内容を述べた。看護師は、専門医療機関内での看護援助とともに、地域に出向く看護援助の母親に与える効果や意義を認識している。 病院内外の看護援助を実施する際には、看護師内面と職場の特色を基にするとともに、援助する上でシステムや連携の問題を認識していることが明らかになった。

Aims and objectives To identify the factors that predict maternal state anxiety when mothers and their sick children visit the outpatient unit of a paediatric hospital. Background While previous studies have focused on predictors of anxiety in mothers with ill children, the existing literature is limited in study design, research timing, respondent characteristics, sample size and data analysis. Design A cross-sectional design with self-administered questionnaires. Methods Mothers were recruited from the outpatient unit of a Japanese paediatric hospital (N = 1077). Participants' state anxiety scores were collected using the Japanese version of Spielberger's State-Trait Anxiety Inventory. The independent variables were the mothers' and sick children's background information. Results Participants were 1077 mothers; 990 provided valid responses. Mothers' mean state anxiety score was 49·72. Significant predictors of maternal anxiety were mothers' childrearing anxiety, child age, the sick child having a fever, sick child having siblings, having a person providing childrearing support, the mother's first visit to the hospital, out-of-hours visit and severity of the child's illness. The overall model explained 21·6% of the variance (multiple regression analysis). Conclusions As various factors predicted maternal anxiety, identifying methods to address these factors may reduce maternal state anxiety. Relevance to clinical practice There is potential for improved understanding of the predictors of maternal state anxiety to aid in the development of materials that would best measure anxiety. The present findings may also suggest some means of providing appropriate information and support to anxious mothers. Our findings cannot demonstrate causation, however, and teaching methods and supportive practices were not investigated; therefore, a qualitative study on the concrete content of maternal anxiety and an intervention study to create support services for anxious mothers is required. In addition, prospective or longitudinal studies are also important for investigating causation.

Summary Objectives We examined whether aromatherapy involving inhalation of yuzu (Citrus ichangensis × Citrus reticulata) oil was effective in decreasing mothers' anxiety for her sick child receiving an infusion at a paediatric clinic. Design Controlled clinical trial. Setting Mothers of sick children who arrived at the hospital were asked to complete an anonymous questionnaire. After a doctor examined the child and confirmed the necessity for infusion, the mothers who agreed to participate in our study were allocated to an aromatherapy or a control group. Interventions A diffuser was filled with yuzu oil before the subjects entered the aromatherapy room. The mother was shown how to use the aromatherapy diffuser while the child was receiving an infusion in the same room. Fifteen minutes after entering the room, the mothers were asked to complete an another questionnaire. Main outcome measures We measured the mother's anxiety with the state anxiety score from the State-Trait Anxiety Inventory. Results There were 60 subjects in the aromatherapy group and 61 in the control group. Both groups were well balanced in terms of demographic characteristics. Using analysis of variance, we demonstrated a significant difference in two-factor interactions between the control and aromatherapy groups. Maternal state anxiety was significantly lower in the aromatherapy than in the control group. Conclusions Inhalation of yuzu oil was shown to decrease maternal anxiety for a sick child. A multicentre randomized controlled trial or double-blind study is necessary to obtain objective evidence of this benefit of aromatherapy.

In vitro and in vivo experiments have shown that topical rebamipide will increase the number of goblet cells in the bulbar conjunctiva. The purpose of this study was to determine whether topical rebamipide will enhance the recovery of conjunctival goblet cells that were damaged during vitrectomy. Forty patients who underwent vitrectomy surgery were studied. The 40 patients consisted of 20 with diabetes mellitus (DM) and 20 patients without DM. They were randomized in a 1:1 ratio into groups that were treated or not treated with topical 2% rebamipide after the surgery. Impression cytology was performed at the end of surgery and at 14 days after the surgery. The mean goblet cell density of each specimen was determined by averaging the total number of goblet cells obtained from three consecutive high magnification microscopic images. In patients without DM, the mean goblet cell density at 14 days after the vitrectomy was significantly higher in eyes with topical rebemipide than in eyes without rebemipide (P P = 0.09). These results suggest that topical rebamipide can be helpful in patients with globlet cell damage that occur during and after vitrectomy.

Purpose. To describe a method of quantifying the size of the retinal hemorrhages in branch retinal vein occlusion (BRVO) and to determine the interrater and intrarater reliabilities of these measurements.Methods. Thirty-five fundus photographs from 35 consecutive eyes with BRVO were studied. The fundus images were analyzed with Power-Point® software, and a grid of 14 squares was laid over the fundus image. Raters were asked to judge the percentage of each of the 14 squares that was covered by the hemorrhages, and the average of the 14 squares was taken to be the relative size of the retinal hemorrhage.Results. Interrater reliability between three raters was higher when a grid with 14 squares was used (intraclass correlation coefficient (ICC), 0.96) than that when a box with no grid was used (ICC, 0.78). Intrarater reliability, which was calculated by the retinal hemorrhage area measured on two different days, was also higher (ICC, 0.97) than that with no grid (ICC, 0.86). Interrater reliability for five fundus pictures with poor image quality was also good when a grid with 14 squares was used (ICC, 0.88).Conclusions. Although our method is subjective, excellent interrater and intrarater reliabilities indicate that this method can be adapted for clinical use.

Due to the broad anti-inflammatory and immunomodulatory actions of phosphodiesterase (PDE) 4 inhibitors, it has been proposed that PDE4 inhibitors might be efficacious for skin disorders such as atopic dermatitis. KF66490 is a newly developed PDE4 inhibitor that inhibits PDE4B (IC(50)=220 nM) and the production of tumor necrosis factor (TNF)-alpha by mouse peritoneal exudated cells stimulated with lipopolysaccharide (IC(50)=855 nM). To evaluate efficacy of KF66490 in atopic dermatitis (AD) models, on skin inflammation induced by repeated application of 2,4,6-trinitro-1-chlorobenzene (TNCB) on ear in BALB/c mice and on spontaneously AD-like skin diseases in NC/Nga mice. BALB/c mice were sensitized with 0.3% w/v TNCB applied to the ear on day-7, followed by application three times a week from days 0 to 21. NC/Nga mice spontaneously developed dermatitis symptoms under conventional conditions. Test compounds were administered orally once daily during experiments. In the TNCB-induced dermatitis model, KF66490 significantly inhibited the increase in ear thickness and interleukin (IL)-4 and IL-1beta levels in the ear. Histopathological and immunohistochemical analysis revealed that KF66490 significantly inhibited the proliferation of fibroblasts and CD3-positive T cells infiltration into the ear. In addition, KF66490 significantly suppressed the development of dermatitis in NC/Nga mice on all observation days, except for 5 and 6 weeks after the first dose. Furthermore, KF66490 produced less potent emetic effects than the first generation PDE4 inhibitor, rolipram. The present results suggest that KF66490 has excellent potential as an oral medicine for the treatment of atopic dermatitis.

The purpose of this study was to evaluate the efficacy of rolipram, a phosphodiesterase (PDE) 4 inhibitor, in a mouse model of dermatitis induced by repeated application of 2,4,6-trinitro-1-chlorobenzene (TNCB). BALB/c mice were sensitized with 0.3% w/v TNCB applied to the ear on day -7, followed by application three times a week from day 0. Rolipram, prednisolone and cyclosporine A were administered orally once daily from day 0 to 21. Rolipram at a dose of 10 mg/kg/day significantly inhibited the ear thickness and the increase in cytokine levels and enzyme activity in the ear. Interleukin (IL)-4 production was markedly decreased in cervical lymph node cells from animals treated with rolipram at a dose of 10 mg/kg/day. Prednisolone and cyclosporine A significantly reduced ear thickness. These compounds significantly decreased the total cell and lymphocyte number of the cervical lymph nodes. Furthermore, prednisolone markedly suppressed body weight gain, and cyclosporine A significantly increased the serum total IgE concentration compared with that in the vehicle-treated control. Rolipram, unlike prednisolone and cyclosporine A, did not influence body weight and the total IgE concentration in the serum. The present results suggest that the PDE4 inhibitor is a promising oral medicine for the treatment of chronic skin inflammatory diseases.

Objective To report the histopathologic findings of 3 corneal buttons incised from 2 patients during penetrating keratoplasty (PKP) because of corneal perforation due to corneal siderosis. Methods Three eyes of 2 patients had accidental trauma to the corneas caused by iron fragments; the injuries were initially treated conservatively with antibiotics and therapeutic soft contact lenses. However, the corneal stroma melted and perforated, necessitating corneal transplantation. The corneal buttons removed during PKP were examined histopathologically, and the findings were compared with the slit-lamp biomicroscopic and anterior segment optical coherence tomographic (AS-OCT) findings. Results Slit-lamp examinations showed that the corneal epithelium was hyperplasic around the area of perforation in 2 eyes 1 month after the injury. Wide areas of the stroma had melted, and the corneas were perforated. The corneal epithelium was atrophic in the perforated corneas 4 months after injury. Histopathologically, the corneal stroma and Descemet's membrane were stained by Prussian blue, suggesting that the ferric ions had penetrated deeper than expected by the slit-lamp examinations. The areas of Prussian blue staining corresponded well with the areas altered in the AS-OCT images. Conclusions Ferric ions penetrate much deeper into the cornea than estimated by slit-lamp biomicroscopy. The ferric ions can induce stromal melting that can lead to corneal perforation. We conclude that ( i ) the ferric ion–infiltrated areas can be estimated in the AS-OCT images and ( ii ) extensive corneal abrasion should be performed to prevent corneal melting and perforation.

Kumiko Kato, Koichi Matsunaga, Yuko Takashima, Mineo KondoDepartment of Ophthalmology Mie University School of Medicine, Tsu, JapanBackground: A congenital nasolacrimal duct obstruction (CNLDO) is a relatively common disease in infants. We evaluated the results of probing three patients with CNLDO, under direct view, with a dacryoendoscope.Methods: Three cases of CNLDO were examined and treated by probing with a dacryoendoscope, under intravenous anesthesia. The diameter of the dacryoendoscope probe was0.7mm, and we were able to observe the inner walls of the lacrimal duct and able to guide the probe through the duct.Results: In all cases, the site of obstruction was detected, and the probe was used to remove the obstruction. At2weeks after the removal of the obstruction, there was no epiphora or mucopurulent discharge in any of the cases. No complications were detected intra- and postoperatively.Conclusion: Although only three cases were studied, we believe that probing with a dacryoendoscope is a safe and effective method of treating a CNLDO. More cases need to be studied.Keywords: probing, epiphora, mucoprulent discharge

Purpose To report the histopathological findings in a case of severe Acanthamoeba sclerokeratitis (ASK). Patient and methods A 46-year-old patient was referred to the Department of Ophthalmology of Mie University Hospital because of a severe corneal ulcer of the right eye of 6 months' duration. Our initial examination showed a ring-shaped corneal opacity with extensive epithelial defects and nodular scleritis. Cysts of Acanthamoeba were identified in cultures from corneal scrapings, and he was diagnosed with ASK. He was started on antiamoebic treatment, including topical micafungin and chlorhexidine. The corneal ulcer was debrided several times. One month later, he developed necrotizing scleritis, and the cornea suddenly perforated. The eye was enucleated because of severe pain and prepared for histopathological examination. Results The histopathological examination showed an infiltration of polymorphonuclear leukocytes throughout the corneal stroma and also in the limbal area of the sclera, forming an abscess. Granulation tissue was observed in the anterior sclera close to the ciliary body, but the posterior regions of the eye were not affected by inflammation or tissue destruction. The cysts of Acanthamoeba were observed only in the cornea. Conclusion Histopathological examination of an eye with severe ASK showed that the inflammation and tissue granulation were present only in the anterior part of eye, and the posterior segment was not affected. Because the inflammation and tissue destruction were confined to the anterior segment, enucleation might not have been necessary if the severe pain was able to be controlled.