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The patient was in his 70s. He was addmitted to our hospital because of obstructive pneumonia for 3 months. Chest computed tomography( CT) showed a nodule at the base of the right B8, obstructing the basal branch, with consolidation of the peripheral lung. Bronchoscopy revealed the right basal trunk obstruction by a tumorous lesion. FDG-PET showed heterogeneous FDG uptake at the right hilum and the lower lobe suggesting malignancy, and a thoracoscopic right lower lobectomy was performed. Pathology showed a granulation-like nodule and a brown oval foreign body incarcerated in the peripheral bronchus, which was later revealed to be a peanut, and no obvious malignant findings were observed.

Only minimal information exists regarding the treatment outcomes of patients suffering from methicillin-resistant Staphylococcus aureus (MRSA) bacteremia treated with teicoplanin (TEIC) when the TEIC minimum inhibitory concentration (MIC) is close to the upper limit of the "susceptibility range" according to the Clinical Laboratory Standards Institute (CLSI). We investigated the outcome of TEIC-treated patients in MRSA bacteremia, focusing on TEIC MIC against MRSA. A retrospective cohort study was conducted on patients with MRSA bacteremia. TEIC treatment failure was defined as any of the following: (1) all-cause 60-day mortality, (2) persistent bacteremia until the end of TEIC treatment, or (3) 30-day recurrence of MRSA bacteremia. Nineteen patients were enrolled, of whom 15 exhibited TEIC MICs ≤2 μg/mL and the remaining 4 exhibited >2 μg/mL. The rate of treatment failure and all-cause 60-day mortality in patients with MIC >2 μg/mL were significantly higher than those in patients with MIC ≤2 μg/mL [4 patients (100%) versus 4 patients (26.7%) (p=0.018) and 4 patients (100%) versus 2 patients (13.3%) (p=0.004), respectively]. Three of four patients (75%) with MIC >2 μg/mL had persistent bacteremia, which was quantitatively higher than in patients with MIC ≤2 μg/mL (1 of 7 patients, 14.3%). Our finding suggests that TEIC MIC >2 μg/mL may be related to poor treatment outcome in MRSA bacteremia, and that TEIC should not be used in this case.

Bacteremia is one of the most serious infectious illness resulting from nosocomial infection. Therefore, appropriate antimicrobial chemotherapy should be provided as soon as possible to patients exhibiting symptoms of infectious disease and having positive blood culture results. Antimicrobial stewardship (AS) guidelines were recently released by the Infectious Diseases Society of America. The guidelines recommend "proactive intervention and feedback" as one of the core strategies for implementing optimal antimicrobial drug use to improve patient outcomes in clinical settings. We began using the AS program for optimizing antimicrobial chemotherapy in patients with positive blood culture results. The results of blood cultures and antimicrobial prescriptions for the corresponding patients were daily reviewed by a pharmacist and a physician, members of the infection control team (ICT). If the antimicrobial agents selected were inappropriate, ICT made a recommendation to the attending physicians who prescribed the antibiotics. To evaluate the outcomes of this program, we conducted a single-center, retrospective investigation for near a hundred of patients who underwent intervention by infection-control physician and pharmacist. Resolution of bacteremia (determined by blood culture results) was 96.3% in the group that accepted intervention, whereas only 16.7% of the cases resolved in the group that did not accept intervention. These results strongly suggest the importance of the infection disease-specialist team intervention. This program could become an important method for improving clinical outcomes in patients with bacteremia.

Middle ear implants (MEIs) such as the Vibrant Soundbridge (VSB) are attractive and alternative treatments for patients with conductive, sensorineural, and mixed hearing loss who do not benefit from, or who choose not to wear, conventional hearing aids (HAs). Recent studies suggest that MEIs can provide better improvements in functional gain, speech perception, and quality of life than HAs, although there are certain risks associated with the surgery which should be taken into consideration, including facial nerve or chorda tympanic nerve damage, dysfunctions of the middle and inner ears, and future device failure/explantation. In Japan, a multi-center clinical trial of VSB was conducted between 2011-2014. A round window vibroplasty via the transmastoid approach was adopted in the protocol. The bony lip overhanging the round window membrane (RWM) was extensively but very carefully drilled to introduce the Floating Mass Transducer (FMT). Perichondrium sheets were used to stabilize the FMT onto the RWM. According to the audiological criteria, the upper limit of bone conduction should be 45 dB, 50 dB, and 65 dB from 500 Hz to 4, 000 Hz. Twenty-five patients underwent the surgery so far at 13 different medical centers. The age at the surgery was between 26-79 years old, and there were 15 males and 10 females. The cause of conductive or mixed hearing loss was middle ear diseases in 23 cases and congenital aural atresia in two cases. The data concerning on the effectiveness and safety of VSB was collected before the surgery and 20 weeks after the surgery. Significant improvements of free-field Pure Tone Audiogram (PTA) from 250 Hz to 8, 000 Hz were confirmed (p < 0.001). Hearing gain up to 40 dB was achieved in the 1, 000 Hz to 4, 000 Hz range. No deterioration in either air conduction or bone conduction at PTA was noted at 20 weeks after the surgery. Monosyllable speech perception in both quiet and noisy conditions improved significantly (p < 0.001). The speech discrimination score in both quiet and noisy conditions improved significantly too (p < 0.001). In the future, it is likely that there will be an increasing population even in Japan that will meet the criteria for MEIs such as VSB. However, the long-term efficacy and safety of these devices should be established.

The Vibrant Soundbridge (VSB) is an active middle ear implant with the Floating Mass Transducer (FMT). We performed a multicenter study to study the efficacy of the VSB by means of "the 10 Questionnaire on Hearing 2002" and "the APHAB questionnaire" at 13 hospitals between 2011 and 2013. In all, 23 patients with mixed or conductive hearing loss received VSB implantation by the round window placement technique. These individuals were generally unable to use, or gained little from conventional hearing aids or bone conduction hearing aids. Two questionnaires were administrated before the surgery and 20 weeks after the VSB implantation. Scores on every item of "the 10 Questionnaire on Hearing 2002" showed significant improvement under noise after VSB implantation. On the APHAB, the scores for Ease of Communication, Reverberation, and Background subscales improved significantly after the VSB implantation, while the score for the Aversiveness subscale alone failed to show a positive improvement from the inexperience to the new sound. Analysis of the responses to these subjective questionnaires revealed better results after VSB implantation as compared to the preoperative data. In conclusion, RW vibroplasty with the use of VSB provided subjective benefit in patients with conductive and mixed hearing loss.

Double- and triple-hit lymphomas (DHL/THL), high-grade B-cell lymphomas with an extremely poor prognosis, are defined by a chromosomal breakpoint affecting the MYC/8q24 locus in combination with another recurrent breakpoint. The successful use of dose-adjusted (DA) EPOCH-R in patients with MYC-positive lymphoma and Burkitt lymphoma (BL) was recently reported. A 74-year-old man with acute renal dysfunction and hyperkalemia was transferred to our emergency center by ambulance. PET-CT revealed a left renal hilar mass enveloping the abdominal para-aortic domain and bladder and hydronephrosis. High (18)F-FDG uptake revealed lymph node, peritoneum, and multiple bone metastases. Analysis of the bone marrow aspirate revealed abnormal lymphoid cells with deeply basophilic cytoplasm and numerous vacuoles resembling Burkitt cells. Chromosomal analysis revealed a complex chromosomal karyotype, including t(14;18)(q32;q21), and FISH analysis confirmed split BCL2, BCL6, and MYC signals. Bone marrow biopsy revealed diffusely infiltrating large abnormal lymphoid cells with a CD10⁺, CD20⁺, BCL2⁺, BCL6⁺, c-MYC⁺ and MUM1(-) immunophenotype. B-cell lymphoma, unclassifiable with features intermediate between diffuse large B-cell lymphoma and BL, was diagnosed. The patient achieved a partial response after eight courses of DA-EPOCH-R chemotherapy. Our experience suggests that DA-EPOCH-R may be an effective treatment for DHL/THL.

An 8-year-old girl of Type 1 diabetes mellitus on insulin therapy, was surgically treated for brain cavernous hemangioma. Since the hemangioma gradually became larger, the medical team including anesthesiologists, neurosurgeons, and pediatricians discussed and decided to perform craniotomy. Preoperative blood sugar level was around 40 to 300 mg x dl(-1) and appeared poorly controlled. During the surgery, opioid-based anesthesia and 1.3% glucose infusion were given to the patient to avoid surgical stress-induced hyperglycemia and to avoid starvation. Intraoperative blood sugar levels were maintained exactly at 100 to 120 mg x dl(-1) without insulin medication, and cortisol levels were below the limit of detection. Postoperative sugar level was difficult to control at the preoperative level Tumor was completely removed and the patient was discharged without any neurological sequelae. This report suggests that sufficient analgesia with remifen tanil and appropriate glucose infusion may be useful for the metabolic management not only in patients without diabetes but also in those with diabetes.

An 80-year-old man was diagnosed with advanced gastric cancer and underwent distal gastrectomy. Although the pathological Stage of the cancer was III A, he refused adjuvant chemotherapy. One year later, CT revealed multiple liver metastases. Therefore, he was started with S-1 administration and a complete response was obtained at 10 months after starting S-1 administration. He has maintained a complete response for 22 months after S-1 discontinuation.

We conducted two studies to develop a Japanese version of the Personal Growth Initiative Scale-II (PGIS-II), and examined its reliability and validity. PGIS-II was developed as a multidimensional measure of the multiple processes of the Personal Growth Initiative (PGI). The PGI describes an active, intentional engagement in the process of personal growth for self-improvement of life experiences. Study 1 (N = 204) reports the confirmatory factor analysis (CFA) of the Japanese version of the PGIS-II. The CFA confirmed that 4-factor model showed acceptable fit indices, with reliability coefficients ranging from .67 to .84. Concurrent validity of the PGIS-II was indicated by the correlation with happiness, the positive score for automatic thoughts. Study 2 (N = 101) reports the concurrent validity of the PGIS-II using scales for locus of control, self-esteem and coping. Results suggested significant correlations between scores on the PGIS-II and locus of control, self-esteem and some coping subscales. The overall results suggest that the Japanese version of the PGIS-II has satisfactory statistical reliability and validity.

Usher syndrome is an autosomal-recessive disorder that causes bilateral sensorineural hearing loss, retinitis pigmentosa (RP), and occasionally vestibular dysfunction. Usher syndrome types 1, 2, and 3 can be distinguished by differences in audiovestibular features. The objectives of this retrospective study were to evaluate 26 patients with Usher syndrome clinically. The 26 patients (male: 12 cases, female: 14 cases) with Usher syndrome, with a clinical diagnosis based on symptoms of bilateral sensorineural hearing loss and RP, had been registered from 13 hospitals as a multicenter study. We assessed the clinical history and performed audiovestibular and ophthalmologic examinations, and genetic testing. Eleven of the patients were classified as having Usher type 1 (38.5%), 6 with Usher type 2 (23.1%), and 9 with Usher type 3 (38.5%). However, many patients with atypical Usher type 1 (70%) and type 2 (83.3%) were found compared with Usher type 3 (10%). The conductive rate of vestibular examinations including the caloric test (50%) was low. There were many variations in the clinical symptoms in Usher syndrome patients, therefore the classification of Usher types 1, 2, and 3 has been complicated. We have proposed a flowchart for the diagnosis of Usher types 1, 2, and 3.

Cervical spinal cord injury is a tragic trauma causing immediate serious quadriplegia and respiratory paralysis. In unstable injuries with paralysis, emergency surgery must be performed immediately to achieve spinal cord decompression and spinal column stabilization. In the treatment of dislocation fractures, first priority should be given to reducing the dislocation, by which the spinal cord is decompressed. A successful attempt to reduce the dislocation using skeletal traction is followed by elective surgery for fixation. In the case of a failure in reducing the dislocation, surgery with a posterior approach is performed to reduce the dislocation and provide internal fixation. In patients with considerably affected anterior column stability and those with any anterior compression that must be eliminated, such as intervertebral disc herniation or a vertebral body fragment, anterior decompression and fixation surgery is indicated.

A 14-day-old neonate was transferred to our university hospital because of respiratory distress and mild disturbance of consciousness. He had no history of abnormal pregnancy or delivery, but had developed apnea at 6 days old. Thereafter, respiratory distress progressed and his condition deteriorated. On admission to our hospital, several vesicles were found on the left upper arm, and moderate hepatomegaly was also present. Herpes simplex virus (HSV) type II genome was detected from serum, spinal fluid, and bone marrow. Laboratory examinations revealed typical abnormalities of disseminated intravascular coagulation, increased levels of serum ferritin, aspartate aminotransferase, and lactate dehydrogenase. Bone marrow aspiration demonstrated activated macrophages and hemophagocytosis. Spinal tap revealed numerous mononuclear cells. Meningitis and virus-associated hemophagocytic syndrome (VAHS) due to systemic HSV type II infection were thus diagnosed. Acyclovir (60 mg/kg/day) and vidarabine were promptly administered. Dexamethasone palmitate and intravenous cyclosporine were also administered for systemic inflammation due to VAHS. Finally, these aggressive therapies rescued the patient without any sequelae. In general, neonatal systemic HSV infection is life-threatening and results in poor intact survival. Our case report suggests that not only antiviral treatment for HSV, but also anti-inflammatory treatment including steroid and cyclosporine should be considered from the early phase of neonatal systemic HSV infection.

The effectiveness of bone anchored hearing aid (BAHA) for the patients with congenital aural atresia was evaluated by multicenter clinical study in Japan. Twenty patients (17 bilateral and 3 hemilateral) of congenital auricular atresia were registered for this study and finally, 18 of them (15 bilateral and 3 unilateral) were subjected to further evaluation. Primary endpoint of this study was free sound-field pure-tone audiometory and speech threshold hearing test in quiet and noisy circumstances. Secondary endpoint of this study was patient's satisfaction based upon APHAB (Abbreviated Profile of Hearing Aid Benefit) questionnaire survey. These results were compared between before and 12 weeks after BAHA surgery. Both hearing level of pure tone and speech threshold significantly improved after BAHA surgery. APHAB scores also suggested the improvement of the QOL after BAHA usage, except for the scores that concerned with unpleasantness of noisy sound. BAHA is one of the useful options for the treatment of congenital auricular atresia.

The prevalence of eating disorders (ED) has increased and these are intractable disorders that require prolonged treatment. The workplace is an important life scene for the patients, but there are few reports available about the current status and correspondence to ED in workplace. Based on a survey of 1248 enterprises, we discuss the cognition of each form of ED. In addition, the background, eating behaviors, and job stress of 2004 workers were also surveyed. Based on these responses, workers who were supposed to demonstrate anorexia nervosa (AN), bulimia nervosa (BN), or night eating syndrome (NES) were identified. The same survey was conducted among outpatients with ED, and the findings were compared with those of a healthy control group. The terms ED, AN, and BN were highly acknowledged in the workplace, but recognition of NES was low. In addition, the prevalence of workers suspected of AN, BN, or NES were 0.27%, 0.21%, and 12.9%, respectively. Based on comparisons of job stress in working ED patients with job stress in workers without ED, and comparisons of job stress in NES workers with job stress in workers without eating problems, specific job stressors were supposed to be associated with ED. These findings indicate the importance of learning appropriate techniques for coping with job stress and the necessity of recognizing abnormal eating behaviors in the workplace.

A 29-year-old man was admitted to our hospital because of high fever and dyspnea. About two months before this admission the patient was diagnosed as Henoch-Schönlein purpura nephritis who was treated with 40 mg/day of prednisolone(PSL). When the dose of PSL was decreased to 32.5 mag/day, his temperature was 40 degrees C, the pulse was 120 beats per minute and the blood pressure was 71/36 mmHg. In the peripheral blood study, the white blood cell count was 23,800/microL and C-reactive protein was 6.1 mg/dL. He was diagnosed as bilateral lower lung pneumonia by chest-computed tomography findings, non-segmental and high-density consolidation of the bilateral lower lungs. Streptococcus pneumoniae was detected from blood culture. Therefore it was concluded that sepsis was caused by severe pneumonia. Thereafter infective endocarditis was diagnosed from the findings of vegetation of both the tricuspid and mitral valves detected by ultrasonic cardiography. Infective endocarditis resulted from septicemia caused by Streptococcus pneumoniae. The infection related endocarditis was completely healed by early treatment including an adequate quantity of penicillin G with high sensitivity. There have been few case reports of infective endocarditis in patients with nephritis under steroid therapy. Steroid therapy is widely used in patients with various types of nephritis including IgA nephropathy and focal segmental glomerular sclerosis in addition to Henoch-Shönlein purpura. Infective endocarditis should be recognized as a complication of steroid treatment of these patients.

Patients with eating disorders are increasing in number. Some neurocircuits concerned with feeding behavior might be dysfunctional in these patients with repeated expression of disorganized eating behavior like long-lasting dieting. These neuronal, or endocrinological dysfunctions might even be enhanced by psychological stress. To understand the biological bases of eating disorders is necessary to establish effective treatment. According to the clinical features of the patients, we have conducted some rat studies. We have found that space restriction stress enhances rebound hyperphagia induced by time-restricted scheduled feeding, and propose the phenomenon as a possible rat model of binge eating. We can speculate some part of the biological bases of human eating disorders, and effective prevention and treatment through such animal models.

Background: We investigated the perioperative usefulness of a kit for simplified measurement of blood theophylline concentration (BTC), Accumeter theophylline (Nikken Chemicals Co.) in asthmatic patients., Methods: Study 1) BTCs were measured by Accumeter at the beginning of surgery in asthmatic patients who had been medicated with oral theophylline. Study 2) BTCs were corrected during anesthesia in asthmatic patients who showed lower BTCs (<8 microg x g ml(-1)) at the beginning of surgery. Study 3) Theophylline was administered to asthmatic patients who had not been medicated with theophylline, and calculated and measured BTCs were compared., Results: Study 1) Measured BTC at the begin- ning of surgery was 8.2 +/- 3.1 microg x ml(-1) (mean +/- SD), and 14 of 31 patients (45%) showed lower BTC. Patients who smoked showed a significantly lower BTC than that of non-smoking patients (P=0.04). Study 2) Five of 10 patients showed lower BTC at the beginning of surgery, but BTC had increased significantly at the end of surgery after i.v. administration of theophylline. Study 3) There was no significant linear correlation between calculated and measure BTCs after i.v. administration of theophylline (R2=0.25, n=10). Although the mean was near zero (0.05) by limits of agreement, 2 SD was large (2.53). There was no patient who showed wheezing during the study., Conclusions: It is important to monitor BTCs perioperatively in asthmatic patients, and Accumeter theophylline is a simple and useful device for management of BTC.

The bone-anchored hearing aid (BAHA) is an implantable bone-conduction device that vibrates the skull directly via a surgically implanted titanium screw behind the ear. The BAHA has advantages for patients with aural atresia or chronic ear drainage, who cannot wear air-conduction hearing aids. We compared the function of BAHA to conventional bone and air-conduction hearing aids based on functional gain and speech discrimination tests in quiet and noisy environments in 2 patients with chronic ear problems. All expressed a clear preference for the BAHA over conventional bone-conduction hearing aids. The BAHA and air-conduction hearing aid provided similar audiological performance when the functional gain of each hearing aid coincided. As the air-bone gap widens, however, audiological performance with the BAHA showed an evident preference, indicating that the width of the air-bone gap is of some help in BAHA preference compared to air-conduction hearing aids.

A 78-year-old male was urgently admitted to our hospital because of consciousness disturbance. Laboratory data showed marked hypercalcemia (17.0 mg/dl), hypophosphatemia, low intact PTH level, high PTH relating peptide (PTHrP) level, normal osteocalcin and normal 1-25(OH)2D level. Computed tomography revealed a right renal tumor with extracapsular extension. Bone scintigram appeared normal. We performed right nephrectomy under the diagnosis of right renal tumor. Pathological diagnosis was poorly differentiated squamous cell carcinoma (SCC) of the right pelvis. Immunohistochemical study of the resected specimen for PTHrP was positive. Therefore, we diagnosed it as renal pelvic SCC with humoral hypercalcemia of malignancy (HHM). After nephrectomy, serum calcium returned to normal, but 5 months after nephrectomy, local recurrence appeared and serum calcium was re-elevated. She died 7 months after nephrectomy.

Background: Combined administration of local anesthetics and an opioid is frequently used in order to minimize the dose of each drug and to reduce adverse effects. Although fentanyl is commonly administered with local anesthetic, side effects of fentanyl increase in a dose-dependent manner. In this study, we determined the optimal dose of epidural fentanyl after gynecological surgery., Methods: One hundred and sixteen adult patients scheduled for elective gynecological surgery were divided into 3 groups according to postoperative epidural analgesics; 0.2% ropivacaine (group R), 0.2% ropivacaine with 2 microg x ml(-1) fentanyl (group RF 2), or 0.2% ropivacaine with 5 microg x ml(-1) fentanyl (group RF 5). Each analgesic was infused at 5 ml x hr(-1) for 48 hr. Pain scores , incidence of NSAIDs administration and side effects were recorded for 48 hr after the surgery., Results and Conclusions: Ropivacaine alone could not provide sufficient analgesia. Although the addition of 5 microg x ml(-1) fentanyl to 0.2% ropivacaine at a rate of 5 ml x hr(-1) improved postoperative pain, side effects caused by fentanyl increased. Supplementing 2 microg x ml(-1) fentanyl provided sufficient analgesia with the least incidence of side effects.

Some reports of impaired glucose tolerance associated with olanzapine (OLZ) treatment have been published before OLZ was marketed in Japan. In Japan, we have been prohibited from using OLZ for patients with diabetes mellitus, since several cases with OLZ-associated impaired glucose tolerance including two deaths from diabetic coma have been reported. Here, we report four cases of OLZ-associated impaired glucose tolerance and review the points to consider in treatment with OLZ. Of our four cases, three cases were new-onset (non diabetes mellitus cases) and the other case was a diabetes mellitus-existent (diabetes mellitus case). In the non DM cases, the time to the onset of impaired glucose tolerance after initiating treatment with OLZ was 8-9 months, and the impaired glucose tolerance immediately improved after discontinuing treatment with OLZ and initiating treatment for diabetes mellitus. Therefore, it is necessary to continue long-term monitoring of the parameters of glucose metabolism for all patients treated with OLZ. Should impaired glucose tolerance develop during treatment with OLZ, treatment with OLZ should be discontinued immediately and treatment for diabetes mellitus should be started if necessary. Although the condition of diabetes mellitus was stable befor initiating treatment with OLZ in the DM case, hyperglycemia developed immediately after initiating treatment with OLZ and the condition remained unstable even after early treatment for diabetes mellitus. Therefore, it is necessary to check for a previous history of diabetes mellitus and hyperglycemia befor initiating treatment with OLZ. Correlations between weight gain and occurrence of impaired glucose tolerance are not clear, so it is necessary to monitor the occurrence of impaired glucose tolerance even in cases without weight gain.

Pseudolarix amabilis Rehd. extract was examined in vitro for antibacterial effects, anti-inflammatory effects, and inhibitory effects on histamine release. Pseudolarix amabilis Rehd. extract was also examined for efficacy on dermatitis in atopic dermatitis model mice (NC mice) and effects on keratinous moisture level and transepidermal water loss in miniature pigs. Pseudolarix amabilis Rehd. extract had antibacterial effects on Staphylococcus aureus, Candida albicans, and Streptococcus pyogenes; however this antibacterial effect varied with the temperature at which and conditions under which Pseudolarix amabilis Rehd. was extracted. Pseudolarix amabilis Rehd. extract at the final concentration of 2 mg/mL significantly inhibited the hyaluronidase activity; and at 0.005, 0.05, and 0.5 mg/mL, it also significantly inhibited the histamine release. In the mice in which atopic dermatitis had been induced, 28-day administration of Pseudolarix amabilis Rehd. extract at 4 and 400 mg/mL significantly inhibited aggravation of dermatitis without having effects on body weight. In the dorsal skin of miniature pigs, Pseudolarix amabilis Rehd. extract at 4 and 400 mg/mL significantly increased keratinous moisture level with the increase in the number of dosing days, and caused no changes in transepidermal water loss. From the above results, it is clear that Pseudolarix amabilis Rehd. extract inhibits both proliferation of bacteria and inflammation caused by antigens. Furthermore, it is suggested that Pseudolarix amabilis Rehd. extract will serve as a medicinal drug which effectively moistens the skin and prevents and heals dermatitis.

Background: The quality of health information available in the World Wide Web is an important issue, but no review of the quality of such information has been performed., Methods: We investigated the quality of information available on the World Wide Web regarding departments/divisions of anesthesiology in 82 specific functioned hospitals in Japan., Results: Eighty-eight percent of the hospitals have their own web site for anesthesiology. Although only general clinical information was available on 64-71% of the web sites, detailed information on clinical results and members having diploma of the board was available on 11-26% of the sites. Regarding education, only 4% of the sites provided information on contents of lectures, whereas 75% of the sites have pages for medical students., Conclusions: Departments/divisions of anesthesiology, especially in specific functioned hospitals, should recognize an important role of web pages for medical consumers (= e-patient) and renew their web sites appropriately and opportunely.

Background: Clerkships for undergraduate clinical training were introduced in Sapporo Medical University School of Medicine in 2002., Methods: Questionnaire surveys by 5 steps Likert measure were conducted by asking the students about the evaluation of each department or division, and overall evaluation was obtained after the clerkships. The questionnaire consisted of 12 questions on 1) orientation; 2) learning chances and provision of teaching materials; 3) feedback, learning promotion and teaching attitude; 4) coordination of human relationship between medical staff and students; and 5) overall evaluation of teacher's physician., Results: The average score for our department was 4.30 (mean, 6th grade of all 26 departments/divisions), and the scores on provision of medical practice (4.69) and the overall teacher's physician grading (4.65) were the best among the all departments/divisions. The evaluation gradings were rather low on chances for medical and health care interviews (3.59); physical examinations (3.83); and description of medical record (3.73)., Conclusions: Reevaluation of the educational program in our department based on the results of the survey is essential for improvement of the program, and further provision of chances, especially for medical interviews, physical examinations and description of medical record is also needed for undergraduate students in the program.

We report a case of benign intracranial hypertension (BIH) caused by all-trans retinoic acid (ATRA) in a patient with acute promyelocytic leukemia. A 21-year-old male was admitted to our hospital with pancytopenia. He was diagnosed as having acute promyelocytic leukemia due to increased promyelocytes, and PML-RAR alpha chimeric mRNA was detected. The administration of ATRA and idarubicin was started immediately. After 26 days of the chemotherapy, he complained of diplopia. Ophthalmologic examination revealed bilateral papilledema and hemorrhage. The cerebrospinal fluid showed an increase in pressure, but no other abnormalities. Computed tomography showed no intracranial abnormalities. The orbital MR imaging showed distension of the perioptic subarachnoid space and flattening of the posterior sclera. A diagnosis of BIH was made. After the discontinuation of ATRA, the symptoms improved and the MR abnormalities disappeared. As far as we know, there have been no reports illustrating MR abnormalities of BIH caused by ATRA, for the diagnosis and monitoring of which orbital MR imaging can provide important clues.

A 59-year-old man without a history of ischemic heart disease underwent elective laparoscopic cholecystectomy under general anesthesia with epidural anesthesia. About 15 min after pneumoperitoneum had been achieved, the patient developed ST elevation and hypotension. Vagal stimulation resulting from stretching peritoneum, the procedure and epidural anesthesia are thought to have induced vasospasm. The ST segment became normal after interruption of CO2 insufflation. A postoperative coronary artery angiogram showed normal coronary arteries, but diffuse coronary artery spasm was seen after intracoronary injection of acetylcholine. The patient was discharged on nitrates. Patients with gall bladder stones sometimes have coronary risk factors of obesity, hyperlipidemia and hyperglycemia. Careful attention should also be given to patients who do not have a history of coronary disease.

Background: Although patient-controlled epidural analgesia (PCEA) is widely known to provide good pain control after abdominal surgery, it has not been popular in Japan. We evaluated the effects of PCEA with background infusion after major abdominal surgery., Methods: Ninety patients scheduled for abdominal surgery were randomly allocated to two groups by treatment with postoperative epidural analgesia: infuser group (n = 48); continuous infusion 5 ml.hr-1 or PCEA group (n = 42); background infusion 5 ml.hr-1, PCEA 3 ml and lock out 30 min. Microject (Sorenson Medical Co, U.S.A.) was used for PCEA machine. 0.2% ropivacaine 100 ml with fentanyl 500 micrograms was administered into the epidural space in both groups., Results: Postoperative visual analogue scale (VAS) at rest and coughing were about 10 mm and 40 mm in both group, respectively, and there were no significant differences between the groups. NSAIDs were effective for rescue analgesia in infuser group to improve postoperative pain as PCEA. Vomiting and sedation were more frequent in infuser group than in PCEA group. Empty battery and machine troubles of unknown origin were observed in 2 and 4 patients, respectively in PCEA group., Conclusions: PCEA with background infusion could improve the management of postoperative pain, and adequate program of PCEA is important to reduce postoperative pain and its side effects.

A 69-year-old male was diagnosed as having prostate cancer with ureter invasion. His serum prostate specific antigen level was not so high (19.6 ng/ml) before treatment, but clinical stage was D2, poorly differentiated adenocarcinoma of prostate. He was treated with chemoendocrine therapy. Prostate cancer with continuous invasion to the middle ureter is rare. To the best of our knowledge, this is the 6th case report of such an unusual invasion of prostate cancer.

The six attentional-style subscales of the Test of Attentional and Interpersonal Style (TAIS, Nideffer, 1976) have been used mainly in the sport psychology area to investigate the relationship between attentional abilities and performance. This study assessed the validity of the Japanese version of the TAIS attentional-style subscales with 157 male and 163 female students. A confirmatory factor analysis failed to validate Nideffer's attentional dimension of bandwidth (narrow to broad attention) and direction (internal to external). The findings replicate previous studies which showed that the structure of the TAIS attention-related subscales is not reasonable and its factorial validity does not meet the needs of psychometrics.

An 80-year-old female with aortic regurgitation and angina was scheduled for aortic valve replacement and coronary artery bypass graft. After the induction of anesthesia, central venous catheter and pulmonary artery (PA) catheter were placed into the right internal jugular vein. At the weaning from cardiopulmonary bypass, we noticed pulmonary artery pressure (PAP) on the monitor indicating the PA catheter tip being wedged. Therefore, we pulled the PA catheter until the wedging PAP wave disappeared. However, immediately after repositioning of the PA catheter, massive fresh bleeding was found in the endotracheal tube. We estimated the cause of pulmonary bleeding was PA rupture due to malpositioned PA catheter because surgeons had not manipulated the PA during the operation. Soon after restarting the cardiopulmonary bypass, pulmonary bleeding was stopped. Examination with fiberoptic bronchoscope revealed no further bleeding and weaning from cardiopulmonary bypass was accomplished smoothly. Postoperative course was uneventful.

Perospirone is a novel serotonin-2 and dopamine-2 receptor antagonist (SDA) developed in Japan. Premarketing trials suggested that this agent was effective in reducing positive and negative symptoms of schizophrenia and had a favorable side-effect profile. However, these trials included only a few elderly patients, so the usefulness of perospirone in this population remains unknown. In this report we describe the treatment of 2 elderly patients with schizophrenia for whom perospirone therapy was efficacious. Case 1 was a patient with acute exacerbation of schizophrenic symptoms after discontinuance of medication. He was treated with 12 mg of perospirone daily and his symptoms reduced markedly from the 4th day of perospirone therapy. Efficacy was assessed by the positive and negative symptom scale (PANSS); all subscales of PANSS (positive symptom, negative symptom, and general psychopathology) reduced and the total score reduced from 78 to 38 by the end of the 6th week of treatment. No side effects such as extrapyramidal symptoms were noted. Thus, perospirone may be a useful antipsychotic for elderly patients with acute schizophrenia. Case 2 was a patient who had severe negative symptoms and extrapyramidal symptoms such as tardive dyskinesia, tardive dystonia, and sialorrhea. She had been hospitalized for more than 7 years. In this patient 12 mg of perospirone was administered daily after 3 mg of risperidone had been tapered off. The negative symptom subscale and general psychopathology subscale in PANSS were gradually reduced after perospirone therapy was started. Extrapyramidal symptoms were assessed by the drug-induced extrapyramidal symptoms scale (DIEPSS), which consists of eight individual parameters and one global assessment, and each parameter is graded on a 5-point (0 = none to 4 = severe) scale. Sialorrhea, muscle rigidity, tremor, dystonia and overall sererity were improved more than 2 points by the end of the 6th week. The clinical course of this patient suggests that the clinical characteristics of perospirone and risperidone may be different, even though these agents are categorized into the same class of antipsychotics, SDA. Because this is a case report, evaluations are limited the clinical properties of perospirone. Further examination is necessary to evaluate the efficacy and safety of perospirone for elderly patients with schizophrenia, who are more vulnerable to the side effect of antipsychotics than the younger population.

For the purpose of examining pathophysiological mechanisms of a memory function in epileptic patients or an utility of fMRI for a presurgical assessment in neurosurgical treatment of epilepsy, activated areas in fMRI during verbal or visual memory task were investigated in patient group of temporal lobe epilepsy and normal subject group. Patient group of temporal lobe epilepsy consisted of 7 cases, of which 3 and 3 cases had left and right temporal foci, respectively, except 1 case having undetermined laterality of temporal foci. Normal subjects were 16 cases. All the epileptic and normal subjects were right-handed except for 1 lefty normal subject. Verbal memory tasks were composed of covert and overt recall tasks of 10 words given auditorily, while visual ones were recall tasks of 6 figures given visually. Eventually, in normal subjects, the left side-dominant medial frontal lobes including the superior frontal and anterior cingulate gyri were mainly activated in fMRI during the covert recall tasks of verbal memory, while the left side-dominant inferior frontal and precentral gyri as the motor language areas were chiefly activated in addition to the medial frontal lobe during the overt recall tasks. Further, the bilateral occipital lobes were activated in fMRI during the recall tasks of visual memory. Also in patient groups of temporal lobe epilepsy, the activated areas in fMRI during these tasks were the same as in normal subject group, regardless of the laterality of epileptic temporal foci. These results suggest that fMRI is useful for the determination of the lateralization of the cerebral hemisphere contributing to verbal memory function and therefore for the presurgical assessment of memory function in neurosurgical treatment of epilepsy.

We describe a case of serotonin syndrome provoked by tandospirone citrate alone, a serotonergic antianxiety agent. A 42-year-old alcoholic woman started to take tandospirone (30 mg/day in 3 divided doses) because of psychosomatic complaints. One month later, dellirium, marked rigidity and myoclonus in the neck and extremities, fever, hyperhidrosis and diarrhoea developed in succession. Tandospirone was discontinued, and all symptoms disappeared within the following 6 days. We diagnosed her condition as serotonin syndrome, although alcoholic withdrawal syndrome might have superimposed. Serotonin syndrome caused by tandospirone alone has not been reported, although it is widely used in Japan.

We studied the effects of nitrous oxide on the relationship between end-tidal sevoflurane concentration and bispectral index (BIS) in patients undergoing abdominal surgery. Anesthesia was maintained with combination of epidural and sevoflurane anesthesia in air (control group; n = 15) or with 67% nitrous oxide (nitrous oxide group; n = 15). The end-tidal sevoflurane concentration was increased by 0.5% every 15 min to 3% and BIS values were recorded at each step. In both groups, sevoflurane decreased BIS values in a dose-dependent manner and the decrease in BIS reached plateau at 2% of sevoflurane. Nitrous oxide with sevoflurane caused more reduction in BIS in comparison with sevoflurane alone. The sevoflurane concentration for BIS at 50 in the nitrous oxide group (0.9 +/- 0.4%) was significantly lower than that in the control group (1.2 +/- 0.4%). The results suggest that the hypnotic effect of sevoflurane was enhanced by the addition of nitrous oxide during abdominal surgery.

We studied 40 patients scheduled for gynecological surgery to evaluate the effects of volume and concentration of lidocaine on epidural anesthesia. We injected lidocaine 300 mg as 1% (30 ml) or 2% (15 ml) through epidural catheter at L 1/2. There was no significant difference in the spread of sensory blockade (cold and pain) and the Bromage scale between the two lidocaine solutions. This result suggests that volume and concentration of lidocaine do not affect the effects of epidural anesthesia.

A 57-year-old female patient underwent combined off-pump coronary artery bypass grafting and abdominal aortic aneurysm replacement. Anesthesia was maintained with propofol, fentanyl, and thoracic epidural anesthesia. Propofol doses were adjusted to maintain bispectral index (BIS) between 40-60. Despite the remarkable hemodynamic changes, BIS remained stable at about 50 during the surgery. The average dose of propofol was 3.3 mg.kg-1.hr-1. The patient awoke an hour after the surgery and was extubated 1.5 hours thereafter. This case report suggests that BIS is a useful index to determine the depth of anesthesia during surgeries which induce marked hemodynamic changes.

We investigated the effect of premixing lidocaine with propofol on a bispectral index (BIS) during propofol infusion. We studied 40 adult patients given mixture of 1% propofol 20 ml with 2 ml of normal saline (control group) or 2% lidocaine (lidocaine group) infused at 2 ml.kg-1.hr-1 for 10 minutes. Heart rate, mean arterial pressure, and BIS were measured every minute. The addition of lidocaine to propofol reduced the incidence of injection pain from 85% to 10% but did not change the induction time. Propofol significantly decreased mean arterial pressure and BIS but there was no difference between the groups. In conclusion, premixing lidocaine with propofol reduces injection pain without affecting the hypnotic effect.

A survey of unexpected cardiac arrests, excluding those associated with cardiac surgery, that had occurred during anesthesia and surgery in the period 1980-1999 was conducted. There was no significant difference between the number of such cardiac arrests that occurred in the 1980 s (29/36,159, 0.080%) and the number in the 1990 s (33/37,643, 0.088%). According to the classification by Keenan et al., there were 3 cases (0.0083%) in the 80 s and 4 cases (0.0106%) in the 90 s that occurred due to anesthetic management. Cardiac arrests due to surgery itself significantly decreased from 21 cases in the 80 s to 6 cases in the 90 s, probably due to proper treatment for massive bleeding, a decrease in the number of cases of anaphylactic shock, and the development of novel anesthetics. Conversely, cardiac arrests due to preoperative conditions of the patients significantly increased from 5 cases in the 80 s to 23 cases in the 90 s. This increase seems to be due to an increase in the number of severe and multiple injuries and an increase in complicated major surgery. The increase in number of cases due to preoperative conditions also depends on coronary spasm and cardiac conduction insufficiency. Taking into consideration the improvement in intraoperative monitoring and the development of novel anesthetics in the 90 s, greater efforts should be made by anesthesiologists to reduce the incidence of cardiac arrest due to anesthetic management, and preoperative evaluation of surgical patients needs to be reconsidered.

Microtubules (MT) are cylindrical polymers of the protein tubulin (TN) alpha, beta-heterodimer, and are known to be the main component of spindles in mitotic apparatus of eucaryotic cells. MT are also involved in many other basic and essential cell functions. There are a number of natural and synthetic compounds that interfere with MT function to cause the mitotic arrest of eucaryotic cells. Such antimitotic agents show a broad biological activity, and can be used for medicinal and agrochemical purposes. On the other hand, they are important also as the biochemical tools for understanding the dynamics of MT network. Most of such antimitotic agents, with a few exceptions, bind to beta-TN. Among them, colchicine (CLC), vinblastine and taxol have played major roles in practical uses as well as in biochemical studies of MT functions. They all bind to beta-TN but their binding sites are different. We have worked on a variety of antimitotic agents that bind to either of colchicine-site, vinblastine-site and taxol-site, in discovery, structures, biological actions and/or interactions with TN. In this paper, the results of our studies on CLC-site ligands were summarized; (1) synthetic analogs of combretastatin A-4 (CBS A-4), isolated as a cytotoxic compound produced by a species of South African tree Combretum caffrum, (2) curacin A (CU-A), a cytotoxic metabolite of a marine cyanobacteria Lyngbya majuscula, and its related compounds. Interactions of these compounds with TN were studied and structure-activity relationships of these two classes of compounds were discussed.