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A 55-year-old woman suffered from diplopia and occipital pain after shoveling snow. She was diagnosed with the right vertebral artery dissecting aneurysm at the level of the axial vertebra and repeatedly had cerebral infarctions in the posterior circulation. She had subluxation of the atlantoaxial vertebra as an underlying disease. Right vertebral angiogram with the head rotated to the left showed the right vertebral artery occlusion and left vertebral angiogram with the head rotated to the right showed stenosis at the C1-C2 level, leading to the diagnosis of Bow hunter's stroke. After wearing a cervical collar and taking 100 ‍mg of aspirin, she had no recurrence of cerebral infarction and later underwent C1-C2 posterior fusion to prevent the recurrence of cerebral infarction. She finished taking aspirin 6 months after the surgery, and there has been no recurrence of cerebral infarction. We report here a case of Bow hunter's stroke, a rare disease, with good clinical outcomes after C1-C2 posterior fusion.

Steroid usage poses a risk of Clostridioides difficile infection (CDI), but high-dose corticosteroid treatment can lead to false-negative CD toxin test results. Moreover, CDI-induced nausea can complicate administration of oral antibiotics, which are typically the primary therapy for CDI. In the present case, a 43-year-old woman diagnosed with EBV-associated T-cell post-transplant lymphoproliferative disorder developed CDI during treatment with cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP). Following five cycles of CHOP, the patient presented with nausea and diarrhea. CT scans revealed swelling in the ileocecal to transverse area of the colon. While the glutamate dehydrogenase (GDH) antigen test result was positive, the CD toxin test result was negative. However, the nucleic amplification test (NAAT) result was positive, confirming the diagnosis of CDI. Oral treatment with fidaxomicin was initially impractical due to persistent nausea. Instead, treatment began with intravenous metronidazole, and was later switched to fidaxomicin pills. Symptoms improved notably within 10 days, and the patient ultimately made a complete recovery. This case underscores the significance of exploring alternative approaches to CDI management, particularly in immunosuppressed patients.

Of 243 resected cases of primary non-small cell lung cancer for ten years in our hospital, we experienced 4 patients (1.6%) of pulmonary pleomorphic carcinoma. All patients were males and heavy smokers. Histologically, the vascular invasion was showed in 3 of 4 patients. In only one patient, recurrence was recognized, and he died 18 months after surgery. The other 3 patients were alive without recurrence for 86, 92, and 60 months after surgery. In general, prognosis of pulmonary pleomorphic carcinoma is very poor. But in my study, 3 of 4 patients of pulmonary pleomorphic carcinoma survive from this disease. As the planning of an appropriate treatment strategy of pulmonary pleomorphic carcinoma,further detailed assessment of adjuvant chemotherapy, such as immune check point inhibitors, will be considered to be necessary.

A 23-year-old male was aware of pain around his left hip joint and visited a nearby orthopedic clinic. Swelling of the right testis was pointed out, and a testicular tumor was suspected. He was referred to the urology department of a local hospital. Blood analysis showed an increase of α-fetoprotein (AFP) (3,620 ng/ml). Computed tomographic (CT) -scan revealed a left iliac bone metastasis and morbid fracture. Right radical inguinal orchiectomy was performed. The pathological examination revealed mixed germ cell tumor (embryonic carcinoma and immature teratoma: 70%, seminoma: 30%). The diagnosis was non-seminomatous germ cell tumor, stage IIIc, and poor risk on the International Germ Cell Consensus Classification. After one cycle of a bleomycin, etoposide and cisplatinum (BEP) regimen, he was referred to our hospital. After a total of 4 cycles of BEP, AFP was normalized. Denosumab was also administered monthly. The CT-scan showed a reduction of bone metastasis and recovery of ossification. Bone biopsy did not show viable tumor cells. Because extirpation of the remaining mass would require resection of the left part of the pelvic bone with significant functional loss of the left limb, we performed close follow-up after an additional 2 courses of the etoposide and cisplatin regimen. The patient is currently alive without recurrence at 45 months after the last systemic chemotherapy.

Objectives: Labor and social security attorneys (LSSAs) are involved in various positions in harmonizing work with disease treatment; however, their qualification requirements do not include knowledge about the same. Expectations of their involvement in harmonizing work with disease treatment are insufficient. This study aimed to identify the competencies expected of the labor and social security LSSAs in harmonizing work with disease treatment., Methods: In step 1, semi-structured interviews were conducted with LSSAs in this field. In step 2, a draft competency list was created based on the interview results. In step 3, the Delphi method was used to conduct a questionnaire survey among LSSAs who had over 10 consultation cases on harmonizing work with disease treatment, and they were asked about the level of importance (how important they thought it was to promote harmonizing work with disease treatment) and level of achievement (how much they had achieved). We also asked them about the competencies they considered necessary and added them as additional items in the draft. In step 4, the results of the previous step were presented to the participants who had given valid answers in step 3, and they were asked whether they would adopt the items as competencies. Items with an agreement rate of 80% or higher were considered competency items. Additionally, we asked them about the level of importance and level of achievement of the additional items created in step 3., Results: In step 1, 24 LSSAs participated, and in step 2, a draft competency list of six major items, 18 medium items, and 71 minor items was created. In step 3, 49 LSSAs participated and 41 cooperated (response rate: 83.6%). Five items were selected for the draft competency list to be newly added. In step 4, 30 LSSAs cooperated (response rate: 73.1%). None of the items had an agreement rate of less than 80%, and over 40% of the items had an agreement rate of 100%. As a result, six major items, 18 medium items, and 76 minor items were selected for the competency list., Conclusions: This study identified the competencies expected of labor and social security LSSAs in harmonizing work with disease treatment. The results of this study can be used as a reference for developing a systematic training curriculum for LSSAs in this field in the future.

The effects of drugs and other low-molecular-weight compounds are complex and may be unintended by the developer. These compounds and drugs should be avoided if these unintended effects are harmful; however, unintended effects are not always as harmful as suggested by drug repositioning. Therefore, a comprehensive understanding of complex drug actions is essential. Omics data can be regarded as the nonarbitrary transformation of biological information about a sample into comprehensive numerical information comprising multivariate data with a large number of variables. However, the changes are often based on a small number of elements in different dimensions (i.e., latent variables). The omics data of compound-treated samples comprehensively capture the complex effects of compounds, including their unrecognized aspects. Therefore, finding latent variables in these data is expected to contribute to the understanding of multiple effects. In particular, it can be interpreted as decomposing multiple effects into a smaller number of easily understandable effects. Although latent variable models of omics data have been used to understand the mechanisms of diseases, no approach has considered the multiple effects of compounds and their decomposition. Therefore, we propose to decompose and understand the multiple effects of low-molecular-weight compounds without arbitrariness and have been developing analytical methods and verifying their usefulness. In particular, we focused on classical factor analysis among latent variable models and have been examining the biological validity of the estimates obtained under linear assumptions.

A 78-year-old man with mitral regurgitation incidentally diagnosed with aneurysm of the left internal thoracic artery(LITA) and several internal thoracic artery-pulmonary artery( ITA-PA) fistulas originating from the aneurysm. To prevent rupture of the aneurysm, ITA ligation was performed during surgery for the mitral valve. Because of the complex anatomy surrounding the aneurysm, the main duct of the ITA was ligated at the peripheral and center of the aneurysm, then arterial fistulae were resected as many as possible. Postoperative computed tomography (CT), however, showed patent LITA and contrast material in the aneurysm. Second stage coil embolization procedure was performed with successful results. Intravascular treatment is effective for ITA aneurysms or ITA-PA fistulae because we can clearly visualize and confirm blood flow during operation.

Background: This study investigated the effect of adjuvant sublingual immunotherapy (SLIT) on inhaled corticosteroid (ICS) dose in patients with pollinosis-associated asthma., Methods: We retrospectively evaluated patients with cedar pollinosis-associated asthma who initiated pharmacotherapy with or without adjuvant SLIT therapy from December 2014 to December 2016 and who continued treatment for 3 years. Changes in ICS dose (fluticasone propionate or its equivalent), antihistamine use, leukotriene antagonist use and intranasal corticosteroid (INCS) use over the 3-year period were compared., Results: The study included 36 and 35 patients in the add-on SLIT and standard treatment groups, respectively. At 3 years, the add-on SLIT group showed a significant decline in ICS dose (p = 0.024). Although leukotriene antagonist use and INCS use did not differ between the two groups, the percentage of patients using antihistamines at 3 years was significantly lower in the add-on SLIT group than in the standard treatment group (p = 0.009); one in three patients on adjuvant SLIT therapy was able to discontinue ICS treatment. Patients who discontinued ICS treatment were younger (44.6±13.3 years vs. 55.0±14.1 years, p = 0.042), had a higher FEV 1 % predicted (109.9±14.4 vs. 94.8±18.6, p = 0.02), and were on a lower treatment step (2.1±0.7 vs. 3.0±0.8, p = 0.002) than those who did not., Conclusion: The addition of SLIT to standard pharmacotherapy resulted in a significant reduction in ICS dose at 3 years.

Aim: This study aimed to improve the understanding of the utilization rates and the characteristics of users of pulmonary rehabilitation (PR) among people with chronic obstructive pulmonary disease., Methods: We used medical and long-term care claims data from between April 2012 and March 2013 from Kashiwa city in Chiba prefecture, Japan. The study participants included patients of ≥63 years of age, who had received outpatient treatment for COPD (ICD-10 codes: J41-J44) two or more times during the study period, and who had been prescribed two or more COPD-related drugs. We extracted data on inpatient and outpatient PR using respiratory rehabilitation fee (I) (II) codes, and on home-based PR using home-care rehabilitation or nursing codes from medical insurance or long-term care insurance data., Results: The mean age of the patients was 76.8 years (total participation: n = 2,708). There were 61 (2.3%) inpatient PR users, 25 (0.9%) outpatient PR users, and 101 (3.8%) home-based PR users. The median duration of usage by the inpatient, outpatient and home-based PR users was 1 month, 2 months, and 11 months, respectively. The mean age of non-PR and outpatient PR users was 76 years, while that of the inpatient PR users and home-based PR users was approximately 80 years. Approximately 20-30% of non-PR users and outpatient PR users were certified for long-term care. In contrast, approximately half of the inpatient users and almost all of the home-based PR users were certified for long-term care., Conclusions: Since the PR utilization rates were low in both hospital-based and home-based settings, it is necessary to take measures to disseminate each PR based on the characteristics of the intervention duration and service users.

A 65-year-old man was emergently brought to our hospital because of rupture of 10 cm hepatocellular carcinoma(HCC) at left lobe in September 2019. He underwent selective transcatheter arterial embolization(TAE)for hemostasis. Enhanced computed tomography(CT)revealed one more 26 mm HCC at segment 8(S8)in addition to the ruptured HCC. Transcatheter arterial chemoembolization(TACE)was performed for both tumors. HCC at left lobe was resistant to TACE, hence we performed left hepatectomy. During the surgery we searched for peritoneal dissemination by using indocyanine green(ICG) fluorography and found 4 nodules with ICG accumulation in the omentum. All the nodules were pathologically diagnosed as peritoneal dissemination. We reported a case in which the ICG fluorography was very useful for detecting small peritoneal disseminations.

In order to analyze the dynamic behavior of neural systems such as oscillations or rhythms, an approach based on the dynamical systems theory may be useful. In the first part of this article, we present an elementary introduction to that approach based on the materials for an author's lecture. In the second part, we introduce our own study related to dopamine and reinforcement learning using that approach, in which we assumed the decay of learned values and propose a possible mechanism of the effects of dopamine depletion on motivation.

Abdominal computed tomography(CT)revealed ileus due to sigmoid colon cancer in a 68-year-old man with abdominal pain, and endoscopic decompression using a transanal ileus tube was attempted. The blood test on the following day showed a marked increase in CRP 46.13mg/dL. Abdominal contrast CT was performed, and mesenteric ischemia was confirmed. Emergency surgery was performed on the same day. The ileum, and ascending, transverse, and descending colon appeared mottled and necrotic and were excised. A specialized diet started on the 5th postoperative day, and parenteral nutrition was used for a long period of time, due to the possibility of short bowel syndrome. The ileostomy and colostomy was closed 57 days after the operation. The patient finished parenteral nutrition on the 88th postoperative day without obvious nutritional absorption disorder and was discharged on the 94th postoperative day as oral intake only. We reported a case of ileus due to colon cancer with non-occlusive mesenteric ischemia(NOMI).

Aim: Labor and social security attorneys (LSSAs) are involved in the field of occupational mental health. However, little attention has been paid to the involvement of LSSAs in this field. This study investigated the occupational mental health competencies that are expected of LSSAs., Subjects and Methods: Our investigation utilized the Delphi method. In Step 1, we conducted semi-structured interviews with LSSAs and then created an initial list of competencies based on the interviews and a previous investigation. In Step 2, we recruited LSSAs with 10 or more cases related to occupational mental health. They completed a questionnaire assessing the importance of their work (how important they felt it was to conduct work related to mental health) and level of achievement (how much they felt they had achieved). The respondents were also asked to provide additional competencies (not listed on the questionnaire) if they regarded them as necessary for their work, and these were later added to the list of proposed competencies. In Step 3, we presented the results of Step 2 to the same respondents and asked them to rate their agreement with the proposed competencies. Items with agreement of 80% or higher were set as competencies. We also asked LSSAs about the level of importance of their work and their perceived level of achievement with regard to the additional items created in Step 2. Items for which the level of achievement fell below the median were extracted even if the level of importance of the work fell at or above the median., Results: We recruited 8 LSSAs in Step 1 and created a list of 68 preliminary competencies in 20 fields. We recruited 57 LSSAs in Step 2, and 45 LSSAs completed the survey (response rate: 78.9%). Seven competencies were added to the list as a result. We recruited 34 LSSAs in Step 3 (response rate: 75.6%) . Two items with an agreement rate of less than 80% were removed, resulting in 73 competencies in 20 fields. One of the items with an agreement rate of 100% was "The plan is based on the merits and disadvantages (risks) for both labor and management.", Conclusions: This study identified the competencies required of LSSAs in the field of occupational mental health. Our findings suggest that specifying these competencies will enable efficient training of LSSAs.

This study aimed to survey the trend of antimicrobial resistance in Escherichia coli obtained from retail meat. We examined the susceptibilities of 1,115 E. coli isolates obtained from chicken, beef, pork, venison, and wild boar meat from 2011 to 2017 in Tokyo to 14 antimicrobials (ampicillin, cefotaxime (CTX), streptomycin, gentamicin, kanamycin, tetracycline (TC), chloramphenicol, nalidixic acid, ciprofloxacin, sulfamethoxazole-trimethoprim, fosfomycin, amikacin, imipenem, and meropenem). Of all the tested isolates, 18.7% (135/721) isolates from chicken, 77.0% (117/152) from beef, 46.6% (89/187) from pork, 100% (28/28) from venison, and 92.6% (25/27) from wild boar meat were susceptible to all tested antimicrobials. Furthermore, TC resistance was the most common, with rates as high as 56.7% (409/721) and 40.6% (76/187) in the isolates from chicken and pork, respectively. CTX resistance was detected in 4.9% (25/506) of the isolates from domestic chicken and 23.7% (51/215) of the isolates from imported chicken. Moreover, CTX resistance rate in isolates from domestic chicken was significantly lower in 2016 (0.9%, 1/111) and in 2017 (0.8%, 1/121) than in 2012 (10.6%, 17/161). In conclusion, E. coli isolates from retail meat were most commonly resistant to TC, and CTX resistance was higher in E. coli isolates from imported chicken than in E. coli isolates from domestic chicken.

A 65-year-old man was admitted to our institution with vomiting and right flank pain. Computed tomography (CT) imaging showed a 21-cm retroperitoneal multilocular cystic tumor which had been identified four years previously. It had increased from 17 to 21 cm. The initial diagnosis was cystic lymphangioma because it was a clear cystic tumor without a boundary or a solid component in the first CT, but later CT revealed an unclear boundary with surrounding organs suggesting malignancy. We decided to resect the tumor because it was symptomatic and might be malignant. The tumor was then resected along with surrounding organs because invasion was suspected. Pathological findings indicated a diagnosis of cystic lymphangioma with chronic inflammation and confirmed complete resection of the tumor. The patient has remained free of recurrence at one year after surgery. This experience indicates that cystic lymphangioma should be completely resected to prevent recurrence.

We report a case of appendicitis with an abscess that was treated with single-incision laparoscopic ileocecal resection with D2 lymphadenectomy because of intraoperative suspicion of appendiceal cancer. A 73-year-old woman was admitted to the hospital because of right lower abdominal pain. She was diagnosed with appendicitis with an abscess. Although single-incision laparoscopic appendectomy was planned, appendiceal cancer was suspected from intraoperative findings. Therefore, we performed single-incision laparoscopic ileocecal resection with D2 lymphadenectomy. The pathological result was moderately differentiated adenocarcinoma in the appendix. Because of the high risk of fStage II appendiceal cancer, adjuvant chemotherapy was administered. Neither recurrence nor metastasis have been detected 7 months after surgery.

A 78-year-old woman was diagnosed with a gastrointestinal stromal tumor(GIST)of the stomach, gradually increasing from 5 years prior. The tumor was suspected to invade the pancreatic body tail and spleen, as observed with computed tomography. Because the patient refused to undergo resection, we administered imatinib mesylate for 6 years. Since early rectal cancer was revealed, the patient was referred for resection and underwent laparoscopic low anterior resection and partial gastrectomy. Histopathologically, the tumor was replaced by tissues with myxomatous changes, and no viable tumor cells were detected. This was a rare case of GIST, resected after long-term chemotherapy by imatinib mesylate, and pathological complete response was achieved.

A 62-years-old female had undergone ascending aortic replacement with homograft for graft infection and mediastinitis after initial replacement of ascending aorta due to acute type A dissection. Ten years after homograft replacement, follow up computed tomography showed acute growing saccular aneurysm of the homograft without infectious symptoms. We urgently performed Bentall procedure and hemiarch replacement successfully. Pathological diagnosis was true aneurysm of the homograft. She was discharged from hospital without any complication and has been quite uneventful 7 years after surgery. True aneurysm of the homograft is very rare and our case is the 1st report of successful reoperation.

Metachronous bilateral hemothorax due to reverse Chance type thoracic fracture is very rare. In this case, we experienced a case of metachronous bilateral hemothorax, triggered by a thoracic fracture in which the anterior component of the spine collapsed, so-called reverse Chance type thoracic fracture. An 83-year-old woman with spinal kyphosis traumatically injured thoracic spine burst fracture, and bone fragments appeared on both sides of the destroyed vertebra. After injury, the left hemothorax also appeared, followed by the right hemothorax causing hemorrhagic shock. In thoracic destructive anterior fracture, we should consider the possibility of metachronous bilateral hemothorax.

A 40-year-old man presented to our department with chief complaints of nausea and abdominal pain, and was diagnosed with small intestine ileus. After hospitalization, he underwent intestinal tract decompression using an ileus tube. A small bowel tumor was suspected as the cause of the intestinal obstruction. We then performed laparoscopic surgery for diagnosis and resection. In the intraoperative findings, stenosis near the small intestine tumor could be confirmed. The patient therefore underwent laparoscopic resection of a segment of the small intestine. Following rapid intraoperative pathological examination, the tumor was identified as well-differentiated adenocarcinoma with metastasis of the intermediate mesenteric lymph nodes. We then performed dissection of the main lymph nodes using small laparotomy incisions. Adjuvant chemotherapy with XELOX(130mg/m2 L-OHP on day 1 and 2,000 mg/m2 capecitabine on days 1-14)was administered for 6 months. Currently the patient is in relapse-free survival.

In this prospective study, we examined the prophylactic effect of itraconazole oral solution (ITCZ-OS) against invasive fungal disease in hematologic malignancy patients. The participants were 36 patients, at least 16 years of age, with hematologic malignancies treated at our hospital. ITCZ-OS 200 mg/day was administered orally twice a day with a target trough plasma concentration of 350 ng/ml. If the patient did not achieve the target trough plasma concentration, the dose was increased. The success rate of achieving the target trough plasma concentration of ITCZ with a dose of 200 mg/day was 63.9%. During the observation period, 2 patients (5.6%) were diagnosed with possible invasive fungal disease according to the EORTC/MSG 2008 criteria. Adverse events were observed in 2 patients (5.6%). The results showed administration of ITCZ-OS while monitoring ITCZ trough plasma concentrations to be effective for preventing invasive fungal disease, and no serious adverse events occurred. Since predicting trough levels in response to ITCZ administrations is difficult, its measurement is necessary to maintain the prophylactic effect of ITCZ.

Chloramphenicol (CP) is recently one of the rarely-used antibiotics. In this study, we present four patients with intractable bacterial meningitis, who were successfully treated with CP and discuss the therapeutic indications of CP in these pediatric cases. The patients were diagnosed as bacterial meningitis at the ages ranging from 2 months to 1 year and 4 months. The causative organisms found in three of the patients were H. influenzae and in the fourth patient, S. pneumoniae. According to the microbial sensitivity tests, these organisms were highly sensitive to antibiotics including ceftriaxone, meropenem and/or panipenem/betamipron. Treatment with these antibiotics was initially effective; however, recurrences of meningitis appeared in all patients. Administration of CP (100 mg/kg/day) started between the 11th and the 58th days, and was continued for 9 days up to 19 days. Their fever had disappeared within four days after the administration of CP, and it was confirmed that all patients completely recovered from meningitis. Two of the patients developed a mild degree of anemia, but soon recovered after the discontinuation of CP. None of them had neurological sequela. We recommend CP as one of the choices for the treatment of intractable bacterial meningitis.

A 74-year-old woman presented to our emergency department with a chief complaint of appetite loss, and already diagnosed dehydration and heart failure. After hospitalization, the signs of heart failure were improved with liquid supplementation and electrolyte revision. At admission, computed tomography incidentally detected a rectal tumor. She underwent colonography, which revealed a huge villous tumor in the rectum. Based on the result of the initial biopsy, it was classified as a group 4 tumor, but additional biopsy of specimens obtained from 6 places led to a diagnosis of group 5 tumor. Then, we performed laparoscopic super-low anterior resection and made an ileal stoma. The electrolyte imbalance was improved and did not recur after the operation. In this case, the electrolyte imbalance caused by the huge villous tumor was electrolyte depletion syndrome (EDS).

Clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) has been recently proposed as a clinical-radiological syndrome. Several causes of MERS have been reported including infectious diseases. We present herein on a case of MERS induced by dengue fever in a Japanese traveler. A 48-year-old male returning from Thailand and Cambodia was admitted for an unknown fever. Following admission, the dengue virus was diagnosed with a positive RT-PCR result. On day 5 of the illness, regardless of reduced fever, weakness suddenly developed in both upper limbs. A cerebral MRI showed hyperintensities in the splenium of the corpus callosum on T2-weighted and diffusion-weighted images. The symptoms resolved completely within two days of onset. The patient was diagnosed as having MERS due to the MRI features and the mild clinical course. Although only a few cases of MERS caused by dengue fever have been reported, the condition is possibly underdiagnosed. It is hypothesized that dengue fever can induce MERS as dengue fever can cause increased endothelium permeability and hypo-sodium which have been proposed in the pathogenesis of MERS. However, there is currently limited evidence for this. Further research is recommended to demonstrate a causal association between dengue fever and MERS.

We report herein on a case of invasive aspergillosis accompanied by a subcutaneous nodular lesion. A 74-years-old male with myelodysplastic syndrome was hospitalized due to high fever and a painful subcutaneous nodule on the left thigh. Chest radiography and CT scans showed multiple nodular lesions of both lungs, and bacterial pneumonia was initially suspected. He was treated with meropenem, but the symptoms did not subside. Three days after admission, we found that β-D-glucan levels were elevated at 52.6 pg/mL. He was treated with liposomal amphotericin B (L-AMB) for invasive fungal pneumonia, and the symptoms regressed thereafter. Excisional biopsy of the nodular lesion showed a cluster of septated and branching hyphae. Serum Aspergillus antigen tests and sputum fungal culture were negative, and the fungal species could not be identified. Thus, we performed in situ hybridization (ISH) and polymerase chain reaction (PCR) with the excised subcutaneous specimens, and as a result Aspergillus fumigatus infection was diagnosed. Invasive aspergillosis with a subcutaneous lesion is a rare case, and we found that treatment with L-AMB was effective. ISH, PCR and measurement of serum trough concentration of AMPH-B are useful in diagnosis and treatment.

For symptom alleviation, subcutaneous continuous injection of octreotide was administered to a patient with pancreatic neuroendocrine tumor (NET) accompanied by multiple hepatic metastases and ascites. The level of the tumor marker neuron-specific enolase decreased to the normal range and cystic necrosis of the tumors was confirmed. There have been some reports on the antineoplastic effects of octreotide on pancreatic NET; therefore, octreotide appears to be a valid option as a therapeutic agent in patients with highly advanced pancreatic NET, in whom administration of molecular targeted or anticancer agents is difficult because of a poor general status.

Although a globe box-type highly contained laboratory with the internationally-recognized biosafety level-4 standards has been constructed in the Murayama Annex, the National Institute of Infectious Diseases, Tokyo, Japan (NIID) in 1981, the laboratory has never been operated as BSL-4 laboratory since its construction. Furthermore, there are no other BSL-4 laboratories in operation in Japan. The evidence indicates that infectious BSL-4 pathogens such as Ebola and Marburg viruses cannot be manipulated in Japan, making it impossible to study the BSL-4 pathogens using the infectious viruses. A large-scale outbreak of ebolavirus disease (EVD) has occurred in the western Africa such as Guinea, Sierra Leone, and Liberia. Furthermore, the highly pathogenic pathogens' infectious diseases outbreaks such as SARS, Nipah encephalitis, Middle East respiratory syndrome (MERS) have emerged in the world. However, BSL-4 laboratories are not present in Japan, making it difficult to study these pathogens and infectious diseases. Because these emerging virus infections are caused by the zoonotic pathogens, the eradiation and the elimination of these infectious diseases are impossible. We need to develop the diagnostics, therapeutics, and preventive measures based on the studies of the highly pathogenic pathogens more in detail using the infectious microbes. Therefore, BSL-4 in operation in Japan is required to minimize the risk of and combat these emerging highly pathogenic pathogens' infectious diseases.

Autoantibodies are associated with various autoimmune diseases. Systemic lupus erythematosus (SLE) is an autoantibody-associated autoimmune disease which affects multiple organs. Although both genetic and environmental factors are implicated in lupus pathogenesis, the etiology of the disease remains elusive. The discovery of CD4(+)CD25(+) regulatory T cells (Tregs) that characteristically express forkhead box p3 (Foxp3) gene have greatly advanced our understanding of immune systems in autoimmune diseases. CD4(+) Tregs can be classified into two main populations: thymus-derived naturally occurring Tregs (nTregs) and induced Tregs (iTregs) generated from CD4(+)CD25(-) precursors in the periphery. Recently, accumulating evidence suggests that these Tregs play important roles in the regulation of humoral immune responses. In this review, we discuss recent findings on the role of Tregs in SLE.

Acoustic respiratory rate (RRa) monitoring has been validated for patients after general anesthesia and has been shown to be a useful technique. However, its feasibility in patients with a tracheostomy has not been assessed yet. Successful monitoring of RRa in a patient with a tracheostomy is described in this case report. A 56-year-old male patient was scheduled for cranioplasty after severe subarachnoidal hemorrhage under general anesthesia. A tracheostomy tube had been placed in the patient because of airway obstruction and altered spontaneous breathing. The acoustic sensor was placed at the usual position and RRa was successfully monitored by Rad 87 (Masimo Corp., Irvine). Statistical analysis was made for comparison of respiratory rate determined by RRa monitoring with respiratory rate visually counted by intensive care nurses. There was no statistically significant difference between the two respiratory rates (P = 0.82). RRa monitoring is useful even in patients with a tracheostomy.

We describe a rare case of sudden blast crisis of chronic myeloid leukemia that occurred after a 13-year durable remission, following allogeneic bone marrow transplantation and donor lymphocyte infusion. A 55-year-old Japanese man was diagnosed with chronic-phase chronic myeloid leukemia 24 years previously. He underwent allogeneic bone marrow transplantation 2 years after diagnosis. Although the disease recurred 6 years after transplantation, the patient achieved remission again by a donor lymphocyte infusion. Despite a 13-year durable remission, the disease later relapsed into a sudden blast crisis. Prednisolone and vincristine combined with imatinib mesylate effectively achieved a major molecular response. However, the disease relapsed repeatedly with central nervous system infiltration. Dasatinib and intrathecal methotrexate, cytarabine, and dexamethasone administration via the Ommaya reservoir controlled disease progression. Nevertheless, the disease became refractory to treatment with the emergence of a T315I Bcr-Abl gene mutation. The patient eventually died 43 months post crisis.

Osteomyelitis is one of the most severe late complications of radiation therapy. The condition can arise from osteoradionecrosis and can be fatal if it occurrs in vertebrae. A 71-year-old woman, who had undergone chemoradiotherapy for hypopharyngeal cancer 6 months previously, presented with severe neck pain. An MRI examination revealed pyogenic spondylitis and an epidural abscess of the neck. Neurological disturbance in the extremities developed despite the administration of antibiotics for 5 days. Drainage and a laminectomy were performed to control the infection and to relieve spinal cord compression. The patient had no postoperative complications at 15 months after surgery. Previous case reports of osteomyelitis and epidural abscess following radiation therapy for head and neck cancer with surgical treatment tended to have a good clinical course. Severe neck pain and a limitation in the range of motion of the neck are considered to be serious clinical features of osteomyelitis. Since infection in the necrotic mucosa leads to pyogenic spondylitis, a repeated cultivation survey of the mucosa is nessesary for adequate antibiotics therapy. For osteomyelitis and epidural abscess following radiation therapy, immediate specific surgical treatment of the involved region is strongly suggested if antibiotics are not effective or spinal cord compression develops.

In case of a disaster, the clinical laboratory's departmental staff is not only responsible for recovery efforts of routine work and the continuation of emergency tests, but also for protecting patients against both dangers and possible risks in the blood collecting room and physiology laboratory. For this reason, we decided to participate in an emergency drill, which focuses on the initial response to a disaster, specifically evacuation procedures and the cessation of phlebotomy operations. Since there were no existing manuals regarding disasters in our blood collection room, we first made a draft disaster plan. Additionally, since we were absolute beginners with regard to training and had inadequate knowledge of disaster countermeasures, we conducted theoretical simulations in advance. We decided to explain the evacuation details and had each participant in the exercise perform their own role in accordance with our scenario. Furthermore, we asked the participants to discuss the effectiveness of the training and seek out ways to improve our manuals. Although this was the first practice for the blood collection room, we were able to achieve our first goal by raising awareness of disaster prevention activities. The precautions against disaster that eliminate accidents require an immense amount of time and effort. Thus, it is necessary to continue training in order to increase the staffs awareness of disaster defense and to continue to improve our skills in the future.

It is known that blood concentration of rocuronium increases after administration of sugammadex, but this is not clear in the case of vecuronium. We report a pediatric case in which serum vecuronium concentration increased following sugammadex administration after prolonged sedation using vecuronium. A 19-month-old girl weighing 7.8 kg had a history of aortic valvuloplasty at 4 months of age due to truncus arteriosus. She presented again to our hospital due to aortic regurgitation. She underwent aortic valvuloplasty and then aortic valve replacement. The postoperative course was complicated with severe heart failure and acute kidney injury requiring peritoneal dialysis. For that reason she required long-term sedation including administration of a large amount of muscle relaxant due to severe low cardiac output syndrome after aortic valvuloplasty. A total of 615 mg (79 mg x kg(-1)) of vecuronium was administered over a period of 24 days. On weaning from mechanical ventilation, 125 mg (16 mg x kg(-1)) of sugammadex was given. Vecuronium concentration measured by high-performance liquid chromatography (HPLC) was 5.03 ng x ml(-1) before sugammadex administration and increase to 13.98 ng x ml(-1) after that. However, blood concentration of metabolic products of vecuronium did not exceed the lower limits of measurement in each sample. She was successfully weaned from mechanical ventilation without recurarizarion. Serum concentration of vecuronium increased after administration of sugammadex because extravascular vecuronium was redistributed to intravascular space according to the concentration gradient induced by binding and clathration of vecuronium. The measured values of vecuronium after sugammadex administration on HPLC represented the total amount of free vecuronium and vecuronium combined with sugammadex. Recurarization might occur after sugammadex reversal in patients after long-term administration of vecuronium, especially if relatively smaller doses of sugammadex were given. We experienced a pediatric case in which serum vecuronium concentration increased following sugammadex administration after prolonged sedation using vecuronium. There is a risk of recurarization after sugammadex reversal in patients after long-term administration of vecuronium.

Background: The analgesic effect of continuous interscalene block with ropivacaine at a low concentration was compared with that of single-shot interscalene block after arthroscopic rotator cuff reconstruction (ARCR)., Methods: Eighty patients scheduled to undergo ARCR from January 2010 to March 2012 were assigned to a group receiving postoperative continuous interscalene block (continuous group, n=46) and a group receiving single-shot interscalne block (single group, n=34). In both groups, ultrasound-guided interscalene block was performed before induction of general anesthesia. In the Continuous group, continuous interscalene infusion with 0.1% ropivacaine was performed up to postoperative 48 hours. Pain intensity (Prince-Henry scale), additional use of analgesics, and adverse effects were recorded. Statistical analysis was performed with Mann-Whitney test, and P<0.05 was considered to be significant., Results: Pain intensity in the continuous group was significantly lower than that in the single group on the night of the day of operation and the morning of the first postoperative day. The frequency of use of additional analgesic in the continuous group was approximately half of that in the single group. No complete motor block was recorded during continuous infusion of ropivacaine., Conclusions: Postoperative continuous interscalene block with 0.1% ropivacaine provided sufficient analgesia without complete motor block.

This paper presents a woman in her 70's with G-CSF producing anaplastic carcinoma of the pancreas(Stage IVb)who underwent chemotherapy by S-1 alone. On FDG-PET after the first course, accumulation of FDG was impaired remarkably. After the second course, the patient died of carcinomatous pleuritis and peritonitis on the 88th day after initiation of treatment. G-CSF producing anaplastic carcinoma of the pancreas is extremely rare and there are no reports with regard to response evaluation by FDG-PET. Thus, this case has significant clinical value.

Neared infrared spectroscopy (NIRS) is one of the recently developed methodologies which can measure cerebral blood volumes to determine the blood hemoglobin (Hb) concentration simultaneously at multiple points with marked time resolution. Monitoring the changes in the Hb concentration yields site-specific readings on blood flow and, thus, on neural activities. The aim of this study was to examine the characteristics of a single event-related oxyhemoglobin concentration [oxy-Hb] changes in patients with schizophrenia using multi-channel NIRS during a word generation task, Japanese 'Shiritori', and single-word generation task in an emotionally charged state induced by three facial expressions of "crying", "neutral", and "smiling" babies' photographs. Thirty-four patients with schizophrenia and 34 age-matched healthy controls participated in the present study after giving consent. In healthy controls, [oxy-Hb] changes when viewing the "crying" baby's photograph were significantly larger than when viewing the "smiling" baby's photograph. On the other hand, in patients with schizophrenia, [oxy-Hb] changes when viewing the "smiling" baby's photograph were significantly larger than when viewing the "crying" baby's photograph. These results suggest that cautions/execution functions in patients with schizophrenia during the single event word "Shiritori" task measured by multi-channel NIRS were impaired. It was also suggested that, in patients with schizophrenia, the affective reaction influenced by each photograph may be different from healthy controls (mismatch). Multi-channel NIRS can be a useful tool for research and clinical purposes in psychiatry.

Background: Ultrasound-guided brachial plexus block (UGBB) makes it possible to block both lateral and medial aspects of the skin overlying the elbow, which are mainly innervated by C5 and T1 roots of brachial plexus, respectively. The effect of UGBB on perioperative pain relief in total elbow arthroplasty (TEA) was evaluated., Methods: Twenty-one patients scheduled to undergo TEA with general anesthesia from January 2009 to December 2010 were assigned to a group receiving UGBB (Block group, n = 10) and a group receiving general anesthesia alone (General group, n = 11). Perioperative anesthetic dose and postoperative pain intensity were recorded. Statistical analysis was performed with Mann-Whitney's U-test, and P < 0.05 was considered to be significant., Results: Median fentanyl doses during the operation in the Block group and General group were 100 microg and 250 microg, respectively (P < 0.05). Numerical rating scale (NRS) in the Block group was significantly lower than that in the General group immediately after the operation (median value: Block group = 0, General group = 4). Although NRS in the two groups was not different from the night of the day of operation, no patient in the Block group needed supplementary opioids., Conclusions: Ultrasound-guided brachial plexus block in patients undergoing TEA reduces perioperative opioid consumption and wound pain in the early postoperative period.

Background: There are limited data about the correlations between amount of anesthetics and variations in vital signs during pediatric cardiac catheterization., Methods: Data in 80 children with congenital heart disease undergoing cardiac catheterization with/without interventional cardiology in 2004 were examined in this retrospective cohort study. Data on blood pressure, heart rate, oxygen saturation, partial tension in end tidal carbon dioxide (PETCO2), and total amount of anesthetics given during general anesthesia were obtained from anesthetic charts. The correlations between amount of anesthetics and those vital signs were analyzed., Results: Median age of the patients was 14 months and median body weight was 8.8 kg. Median rates of variation in heart rate, blood pressure, oxygen saturation and PET(CO2) were 22.8%, 29.3%, 5.9% and 10.8%, respectively. Although there were no statistical correlations between those vital signs and amounts of anesthetics such as fentanyl, vecuronium and sevoflurane, rates of variation in heart rate was smaller in patients for whom the amount of fentanyl given was more than 4 microg x kg(-1) x hr(-1)., Conclusions: There were no associations between amount of anesthetics and variations in vital signs in pediatric cardiac catheterization.

A 37-year-old man underwent lobectomy of the right liver for granulocyte colony-stimulating factor (G-CSF) producing hepatocellular carcinoma accompanying type B hepatitis. Within two months after the surgery, lung metastases were revealed and administration of sorafenib was begun, however, the lung metastases continued to enlarge. Changing the patient's medication to tegafur-uracil provided remarkable reduction of the lung metastases. The patient is alive two years after diagnosis and receives outpatient chemotherapy. We concluded that this case is valuable with regard to the extreme rarity of G-CSF producing hepatocellular carcinoma and its successful treatment in this case.

We report 2 cases of retroperitoneal liposarcoma. Case 1: A 53-year-old woman with severe abdominal distension and dyspnea was admitted to our hospital. Abdominal computed tomography(CT) and magnetic resonance imaging(MRI) revealed a large mass that occupied almost the entire abdominal cavity. She underwent surgery under the diagnosis of retroperitoneal liposarcoma. The tumor originated from the left lower pelvis. The tumor weighed 18 kg, and the histopathological diagnosis was well-differentiated liposarcoma. Seven years after the operation, local recurrence was found without any complaints. The operation was performed again. The tumor weighed 750 g, and it originated from the same area as observed in the first operation. The histopathological diagnosis was well-differentiated liposarcoma. Case 2: An 82-year-old woman complained of abdominal distension. A new dumbbell-like solid tumor was identified as retroperitoneal liposarcoma by CT and MRI findings, and it was growing rapidly. The tumor was removed with the cecum and right kidney in a curative operation. The tumor weighed 2.6 kg, and the histopathological diagnosis was dedifferentiated liposarcoma. The best treatment for retroperitoneal liposarcoma is curative resection. However, dedifferentiation occasionally occurs over time and in recurrent cases. It is important to follow-up strictly for retroperitoneal liposarcoma.

An excimer laser sheath has recently been used for extraction of pacing and ICD leads. By using this technique, leads are removed more easily and it has to take a shorter time to extract leads. Although lead extraction with this method can cause fatal complications such as large vessel injury, little has been reported regarding anesthetic management during the lead extraction. We experienced two cases of pacing lead extraction using an excimer laser sheath under general anesthesia. The procedures were mainly performed by cardiologists in the operating theater. A wide area was prepared with sterile drapes as for cardiac surgery with cardiovascular surgeons standing by. Vascular access catheters were placed in the right femoral artery as well as vein, and in the right internal jugular vein so that immediate PCPS introduction could be performed in case of sudden hemodynamic collapse by massive bleeding. In the first case, lead extraction was completed without any complication, but in the second case sternotomy was performed by cardiac surgeons for safe separation of leads from vessels. There were also no bleeding episodes in the second case. Preparation for bleeding and cooperation among cardiologists, cardiovascular surgeons, medical engineers and anesthesiologists are necessary from the safety point of view of this procedure under general anesthesia.