Search

Ankle instability often persists even after recovery from ankle sprain and causes recurrent ankle injuries. In addition, ankle instability prolongs the peroneal reaction time (PRT). Acupuncture is used as a treatment in many cases of ankle sprains. The purpose of this study was to investigate the influence of electro-acupuncture stimulation on ankle instability. We studied 15 ankle instability cases and 15 healthy ankles of a total of 15 collegiate footballers. Tests were conducted to measure the PRT: a trap door that simulated the mechanism of nonpathological inversion-ankle sprain was used, and electromyography (EM) of the peroneus brevis muscle was performed. After the first test, electro-acupuncture stimulation was applied for 10 minutes to the peroneus brevis muscle, and then the second test was conducted to investigate the difference in the PRT. We observed that the PRT of the subjects with ankle instability was significantly prolonged compared to that of the subjects with healthy ankles(p<0.05). After the electro-acupuncture stimulation, the PRT in the latter group did not change, but that in the former group was significantly shortened (p<0.05). Thus, our findings suggest that electro-acupuncture has a beneficial effect in subjects with ankle instability. [ABSTRACT FROM AUTHOR]

Copyright of Journal of Japan Academy of Midwifery is the property of Japan Academy of Midwifery and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Cancer cachexia causes anorexia and metabolic disorders, eventually leading to sarcopenia, which in turn contributes to the development of functional disabilities. Although anamorelin hydrochloride tablets are marketed to treat cancer cachexia, their efficacy varies significantly among patients. Here, we investigated the efficacy of anamorelin and the factors associated with weight gain. The factors that contributed to weight gain in patients before starting anamorelin were as follows: the patients' disease stage had not progressed to refractory cachexia based on the cancer cachexia classification of the European Palliative Care Research Collaborative; the patients had received fewer lines of anticancer treatment at the start of oral administration of anamorelin; and the patients had not met all the criteria for starting treatment with anamorelin, namely, C-reactive protein level >0.5 mg/dL, hemoglobin level <12 g/dL, and albumin level <3.2 g/dL. These results suggest that early administration of anamorelin hydrochloride tablets may increase the response rate when cancer cachexia is diagnosed.

Small cell carcinoma of the bladder (SCCB) is a rare cancer that accounts for approximately 1% of primary malignant bladder tumors. It is highly malignant and has a poor prognosis. Similar to small cell lung cancer, platinum-based chemotherapy is recommended as the first-line therapy, and amrubicin (AMR) is recommended as the second-line therapy, but there is no established therapy after the second line. We report a case of SCCB that was refractory to multiple chemotherapies but responded to pembrolizumab. A 77-year-old male, diagnosed with clinical stage T3N0M0 small cell carcinoma and invasive urothelial carcinoma by transurethral resection of bladder tumor (TURBT), underwent robot-assisted radical cystectomy after three cycles of neoadjuvant cisplatin-irinotecan chemotherapy, and pathological examination revealed only small cell carcinoma in his cystectomy specimen. After three courses of adjuvant carboplatin-etoposide chemotherapy, the patient developed liver and bone metastases. Furthermore, after two courses of amrubicin, we started pembrolizumab due to the progression of metastases. Metastases decreased after starting pembrolizumab and continued to decrease after discontinuation because of immunerelated adverse events (irAEs). Therefore, pembrolizumab may be an option for the treatment of refractory SCCB.

The main goals of acquired hemophilia A (AHA) therapy are to arrest bleeding using bypass agents and eradicate FVIII inhibitors using immunosuppressive therapy (IST). We treated a total of 25 patients with AHA in the past 10 years at Gunma University Hospital. Fifteen patients (60%) underwent rehabilitation during hospitalization. The median time from admission to the start of rehabilitation was 31 days (7-142 days). Median FVIII activity at the start of rehabilitation was 11.3% (2.9-79.8%), and median FVIII inhibitor was 2.1 BU/ml (<5.0-46.8 BU/ml). Only one patient (6.7%) had a bleeding event triggered by rehabilitation.

A 79-year-old man was diagnosed with esophagogastric junction adenocarcinoma, cT3N3M0, cStage Ⅲ, including enlarged lymph node metastases(Bulky N)in the middle mediastinum and intraperitoneal. A total of 2 cycles of S-1 plus oxaliplatin(SOX)was administered. After neoadjuvant chemotherapy, the primary tumor and enlarged lymph nodes had greatly decreased in size. Subsequently, thoracoscopic subtotal esophagectomy and reconstruction with a gastric tube were performed. Histopathological examinations showed no residual cancer cells in the primary lesion and dissected lymph nodes (pathological complete response). Preoperative chemotherapy containing SOX could be a useful treatment strategy for patients with esophagogastric junction adenocarcinoma with enlarged lymph node metastasis.

Although trastuzumab biosimilars have been approved based on clinical studies on their use as monotherapy or in combination with chemotherapy, clinical studies on their combination with pertuzumab are lacking. Data on the efficacy and safety of this combination are scarce. We evaluated the efficacy and safety of trastuzumab biosimilars in combination with pertuzumab. Progression-free survival was 10.5 months(95% confidence interval[CI]: 3.3-16.3)for a reference biological product and 8.7 months(2.1-not applicable)for biosimilars with a hazard ratio of 0.96(95%CI: 0.29-3.13, p=0.94); however, no statistically significant difference was observed. The incidence of adverse events was not significantly different between the reference biological product and biosimilars, and no increase was observed for any adverse events after switching to the biosimilars. The results of this study verify that a combination of trastuzumab biosimilars with pertuzumab is sufficiently effective and safe in clinical practice.

The patient was a 42-year-old woman. After 4 courses of capecitabine therapy for right chest wall recurrence of breast cancer, ER(+, 10-15%), PgR(-), HER2(-), she underwent pleurodesis using OK-432 for increased right pleural effusion. On the 12th day after pleurodesis diffuse infiltrative shadows in the right lung, and frosted shadows in both lungs, were observed, and she was diagnosed with drug-induced lung injury. About 3 weeks after administration of prednisolone 1 mg/ kg a tendency for improvement in lung injury was observed, but the patient died of breast cancer progression. Drug- induced lung injury by pleurodesis carries the risk of delaying resumption of chemotherapy. We report this case with a review of the literature.

During laparoscopic cholecystectomy, an 89-year-old man was discovered to have a prolonged APTT. He was transferred to our hospital for a thorough examination because wound bleeding necessitated a reoperation. Based on coagulation factor VIII activity (FVIII:C) of 3.6% and FVIII inhibitor levels of 48.5 BU/ml, he was diagnosed with acquired hemophilia A (AHA). Due to concerns about his advanced age and postoperative infection, immunosuppressive therapy with prednisolone 0.5 mg/kg/day was initiated. His clinical course was favorable, except hemorrhagic shock caused by intramuscular hemorrhage on the right back, although low FVIII inhibitor levels persisted for more than a month; additionally, lower leg edema and increased urinary protein were also observed. He was diagnosed as with AHA and secondary nephrotic syndrome, possibly because of early gastric cancer. As a result, radical endoscopic submucosal dissection (ESD) was performed while a recombinant coagulation factor VIIa preparation was administered. AHA improved rapidly following ESD, and coagulative remission was achieved. Simultaneously, the nephrotic syndrome improved. Because the control of malignant tumors may improve the status of AHA, the timing of malignant tumor intervention must be considered considering the risk of bleeding and infection associated with immunosuppression.

An 86-year-old Japanese male patient visited a nearby hospital with painful swelling in his left upper and lower limbs 35 days after the second dose of the BNT162b2 mRNA coronavirus disease-2019 (COVID-19) vaccine. He was referred to our hematological department due to a prolonged activated partial thromboplastin time and was urgently admitted. He was diagnosed with acquired hemophilia A (AHA) based on factor VIII (FVIII) activity of 1.7%, FVIII inhibitor of 152.3 BU/ml, and FVIII-binding antibodies detected by enzyme-linked immunosorbent assay. Immunosuppressive therapy with prednisolone (PSL) at 0.5 mg/kg/day was started owing to the risk of infection due to old age and poor activities of daily living. Hemostasis treatment with bypass hemostatic preparations (rFVIIa preparation, FVIIa/FX) was administered for each bleeding event, such as intramuscular and knee joint bleeding, resulting in good hemostatic effects. Coagulative complete remission was achieved on day 69 with PSL treatment; however, FVIII activity decreased with PSL tapering. AHA relapse with rectus abdominis muscle hematoma was observed after the third vaccination. This is the first Japanese report of AHA after COVID-19 vaccination and the world's first case, in which the presence of anti-FVIII-binding antibodies were observed.

Peptide receptor radionuclide therapy(PRRT)is a pioneer drug in the rapid development of radio-theranostics, and a paradigm-shifting approach to treat neuroendocrine tumor( NET). The NETTER-1 trial for NETs of the midgut is currently the only global phase Ⅲ prospective clinical trial demonstrating the efficacy and safety of PRRT. In Japan, phase Ⅰ and Ⅰ/Ⅱ trials for lung and gastroenteropancreatic NETs were also conducted, and regulatory approval was granted in June of 2021. Although regulatory approval was obtained in Japan without specifying the primary organ or the history of treatment, there is limited evidence at this time, and guidelines recommend use after the second-line for midgut NETs and in the last phase for all other NETs. PRRT is expected to be utilized as upfront therapy, and the results of ongoing prospective clinical trials are awaited. The effect of PRRT is corelated with accumulation rate of somatostatin receptor scintigraphy(SRS). Sometime accumulation rate of SRS is not constant among multiple tumors in even one patient, then effective use of PRRT is depending on detailed exploration for result of SRS of each tumor. In order to perform this treatment in Japan, a special ward dedicated to radionuclide therapy or at least" a special measures patient room" prescribed by laws and regulations is necessary." A special measures patient room" is a general patient room with temporary isolation and taking radiation protection countermeasure, instead of the special exhaust and drainage systems of radionuclide therapy ward. On the other hand, in order to operate the rooms, it is necessary to set up and decontaminate the rooms for each treatment, which requires specialized knowledge and manpower. Since there is a growing demand for radionuclide therapies, it is important to promote the appropriate introduction of this therapy and to establish a collaborative network for this purpose.

From a young age, a 63-year-old Japanese man had experienced difficulties with hemostasis during tooth extraction and epistaxis and swelling of bruised areas. He had previously been diagnosed with mild hemophilia (FVIII:C 8.5%) at age of 60 due to swelling of a right hip bruise and was administered FVIII concentrate for the first time. He had frequent bleeding around his shoulder joints and was given FVIII concentrates every time, but his hemostasis was poor. He was referred to our hospital because his FVIII activity decreased to<1% and a low-titer inhibitor (2.0 BU/ml) was detected. Because of a shoulder hematoma and new subcutaneous bleeding on both forearms, recombinant FVIIa was used to perform the hemostatic treatment. Following hemostasis, emicizumab was administered subcutaneously every 2 weeks at a dose of 3.0 mg/kg. Approximately 2 months after starting emicizumab, inhibitors were no longer detected, and FVIII activity increased to 8% after 9 months. We encountered a case of mild hemophilia A with an inhibitor that was first diagnosed in old age. The incidence of inhibitors in non-severe hemophilia A is about 10%, and about 70% of those resolves spontaneously. In this case, suppression of bleeding by emicizumab may have contributed to the spontaneous disappearance of the inhibitor.

Neuropsychiatric symptoms comprise one of the five classic symptoms of autoimmune thrombotic thrombocytopenic purpura (aTTP). Although aTTP is typically transient, it is sometimes complicated by cerebral infarction with residual disability. This report presents the case of an 87-year-old man previously admitted to a different hospital with fever and transient consciousness loss. After receiving platelet transfusion with diagnosis of Evans syndrome, he was transferred to our hospital with worsening consciousness disturbance. He was subsequently diagnosed with aTTP with a PLASMIC score of 6 points, ADAMTS13 activity of less than 0.5%, and its inhibitor of 7.4 BU/ml. Platelet count and consciousness were rapidly improved with plasmapheresis and steroids, but motor aphasia emerged. MRI showed multiple cerebral infarctions, including a large infarction in the left frontal lobe. Thus, unfractionated heparin was administered. When his platelet count dropped once again on the 20th day, rituximab was added. The treatment eventually proved to be successful, and his aTTP remained in remission one year after the onset. Treatment for cerebral infarctions was switched to DOAC, and rehabilitation was continued. However, his ADL has not yet recovered. Advances in aTTP treatment have cured many similar cases. Thus, rituximab is now considered a treatment option for refractory cases. However, ischemic organ damage in acute phase and sequelae are observed. Therefore, early diagnosis and novel therapy are required.

Asthma therapy in general has improved a lot in recent years, but it is still a major problem that severe asthma, which accounts for 10 to 20%, still suffers from strong symptoms on a daily basis despite all therapeutic agents used in combination. American SARP and European ENFUMOSA started in 2000 to advance pathophysiological insights of severe asthma. Clinical usage of antibodies and inhibitors against IgE, TNF, IL-5, IL-4, IL-13, and TSLP are also accumulating. Some of these molecular-targeted drugs improve respiratory function and reduce acute exacerbations in patients with severe asthma. Until now, cytokines have been assumed to be involved in chronic inflammation, but it is also interesting to elucidate the pathways of how cytokines are involved in respiratory function and acute exacerbations. We registered approximately 100 steroid-dependent asthma patients in Japan. Although long-lasting poor control of the disease was considered the cause of severe asthma in the past, steroid dependence in one third of the cases occurred within 2-3 years after the onset. Steroid resistance seems a key process from the early stage of the disease. Steroid resistance of T cell level was induced by extracellular co-stimulation and cytokine signals. The inhibition may improve steroid sensitivity and treat steroid-resistant asthma. Therefore, we established a steroid-resistant asthma model for the first time by transferring steroid resistant T cell clones, and analyzed the steroid sensitivity recovery effect of CTLA4-Ig. In addition, a multicenter, double-blind, placebo-controlled exploratory trial was performed as a POC study investigating the efficacy of abatacept in treatment-resistant severe asthma. Elucidation of the pathophysiology and mechanism by which steroids do not work is expected to be a breakthrough for the prevention and treatment of severe asthma.

After the identification of the new coronavirus disease(COVID-19)in December 2019, it has spread rapidly around the world. The COVID-19 pandemic has forced medical systems to limit their services, promote telehealth, prolong visits to clinics, and postpone scheduled surgical operations. The mortality rate of COVID-19 in patients with lung cancer appears to be significantly higher than that of patients with other cancers. Medical care offered to patients with lung cancer should take into account the risk of COVID-19 associated with visits to clinics and treatments. This review outlines the efforts of lung cancer oncologists in the"With COVID-19"era based on the current evidence and statements from domestic and foreign academic societies and organizations.

In the present study, influences of pleural adhesions on thoracoscopic lung surgeries were investigated. A total of 666 consecutive patients who had undergone thoracoscopic surgeries for lung malignant tumors were retrospectively analyzed. Pleural adhesions were present intraoperatively in 289 cases, of which 6 required conversion to thoracotomy due to the adhesions. The influences of pleural adhesions on the perioperative period were comparatively large under following conditions (level-A); the adhesion-type was tight which meant lung and pleural wall sticked closely even if lung collapse was encouraged, the strength was middle( required sharp-dissection) or strong( hard to dissect between visceral and parietal pleura), and the range was more than 10% of total pleural surface. Significant influences of the level-A of pleural adhesions were as follows;prolonged operation time in all procedures, frequent intraoperative lung fistula and prolonged pleural drainage period in wedge resections, and increased blood loss, intraoperative and postoperative lung fistula with prolonged pleural drainage time and postoperative hospitalization period in lobectomy. Other postoperative complications (pneumonia, empyema, exacerbation of interstitial pneumonitis, and arrhythmias) were not associated with pleural adhesions. Careful dissection procedure for pleural adhesions that minimize damage of visceral pleura would be the most important.

An 86‒year‒old man with chronic kidney disease underwent surgical resection for combined large‒cell neuroendocrine carcinoma of the left lower lobe of the lung(pT2aN1M0, stage ⅡB). Five months later, multiple liver and bone metastases and mediastinal lymph node recurrence were detected. After 9 courses of amrubicin monotherapy(32 mg/m2 for 3 consecutive days), his tumor marker levels normalized, and radiological examination revealed a complete tumor response. Adverse events occurred, but they were tolerable except a decrease in the neutrophil count. The patient remained in good condition for several months but died of tumor relapse 22 months after the initial recurrence. Amrubicin monotherapy was considered to be one of the treatment choices for recurrent large‒cell neuroendocrine carcinoma of the lung in elderly patients.

Objective　Polypharmacy in elderly individuals may cause reduced flow of saliva and xerostomia. A dry mouth can lead to poor oral function; however, there are no reports on the relationship between polypharmacy and subjective or objective oral dysfunction. The purpose of this study was to clarify the relationship between the number of prescribed medications and subjective and objective oral dysfunction.Methods　The subjects of this study were 215 community-dwelling, elderly individuals, aged 75 years or older, who visited the dental clinic in the Chubu region for a dental health examination from January to February 2019. A medical interview was conducted to assess three items that were related to subjective oral function and record four measurements related to objective oral function. In addition, information was collected on the diseases being treated and prescribed medications. A subject with a decrease in any of the three subjective oral function categories was considered to have subjective oral dysfunction. Objective oral dysfunction was analyzed with respect to two types of oral dysfunction: a decrease in all four objective oral functions and a decrease in two or more of the four objective oral functions. Logistic regression analysis was performed to examine the relationship between subjective and objective oral dysfunction after adjustment for sex, age group, inveterate disease, and the number of prescribed medications.Results　Individuals who had eight or more prescribed medications had lower subjective oral function than those with seven or fewer medications (odds ratio, 95% confidence interval: 2.3, 1.0-5.1; P<0.05). Individuals with eight or more medications had lower scores in all four objective oral functions than those with seven or fewer medications (4.4 : 1.5-12.6, P<0.01). A decrease in two or more of the four objective oral functions was related to 10 or more prescribed medications (4.3 : 1.2-16.2, P<0.05).　In addition, taking eight or more prescribed medications was associated with a decrease in either subjective oral function or all four objective oral functions (8.1 : 2.1-30.8, P<0.01). A decrease in either subjective oral function or two or more objective oral functions was related to taking 10 or more prescribed medications (4.9 : 1.6-15.6, P<0.01).Conclusion　In conclusion, more than eight prescribed pharmaceutical medications in the elderly is associated with subjective or objective oral dysfunction.

A man in his thirties was admitted to the hospital because of upper abdominal pain. Computed tomography showed intussusception in the ascending and transverse colon. After spontaneous discontinuation, endoscopy revealed a 25-mm 0-I tumor in the ileum. An emergency operation was performed the next day due to intussusception recurrence. The tumor was hyperplastic intestinal epithelium with dendritic smooth muscle fascicles and partly cancerous. The patient had no clinical features of Peutz-Jeghers syndrome. Therefore, the patient was diagnosed with Peutz-Jeghers type polyps based on pathological findings. This case is considered to be a rare case of intussusception in the transverse colon due to Peutz-Jeghers type polyp with canceration.

Ciguatera poisoning (CP) is one of the most abundant seafood poisonings in the world. CP frequently occurred in the tropical and subtropical Indo-Pacific Ocean and the Caribbean Sea. In Japan, CP cases have been reported annually, from the subtropical regions, including Okinawa Prefecture and Amami Islands, Kagoshima Prefecture. The principal toxins, named ciguatoxins (CTXs), are bio-synthesized by benthic dinoflagellate of genera Gambierdiscus and Fukuyoa. They are bio-transferred herbivorous animals to carnivorous fishes via the food chain.The Ogasawara Islands comprise more than 30 islands, Mukojima Islands, Chichijima (Bonin) Islands, Hahajima Islands, Iwo Islands, Nishinoshima, Minamitorishima, and Okinotorishima, which locate in the tropical to subtropical regions. The Mukojima Islands, Chichijima Islands, and Hahajima Islands locate approximately the same latitude as Okinawa. The distance from Tokyo is approximately 1,000 km for Chichijima, 1,700 km for Okinotorishima (the southernmost tip of Japan), and 1,900 km for Minamitorishima (the easternmost tip of Japan). These islands exist in a wide range of waters, latitudes from 20°25' to 27°44' North and longitudes from 136°04' to 153° 59' East. We collected 65 specimens of a grouper, Variola louti, the most frequent species implicated in CP in Japan, from the waters around the Chichijima, Mukojima, and Hahajima islands. The fish flesh specimens were analyzed CTXs using the liquid chromatography-tandem mass spectrometer (LC-MS/MS). While the peak whose retention time is almost identical to that of CTX1B was detected in all specimens on our routine protocol, no 52-epi-54-deoxyCTX1B nor 54-deoxyCTX1B was detected. The peak retention time was quite different from that of CTX1B when re-analyzing by changing the analytical column. Thus, the CTXs in the specimens in the waters of these islands seemed to be undetectable levels.

Ependymoma is the most common primary intramedullary tumor of the spinal cord, accounting for a quarter of these tumors. We experienced a case of 'ependymoma of the spinal cord with a cystic lesion that presented as an intradural extramedullary tumor extending from the thoracic to lumbar vertebrae. In review of past literature on reports of spinal intradural extramedullary ependymoma, lesions spanning three or more vertebrae with cystic lesions were frequent, and about half were World Health Organization grade II or higher. Dissemination or recurrence of these tumors may occur after surgery. There is no consensus on postoperative adjuvant therapy for intradural extramedullary spinal ependymoma, but careful consideration should be given to the intraoperative findings and the characteristics of the tumor.

The patient was a 26-year-old female who had undergone conservative treatment for acute appendicitis at another clinic and was referred to our hospital for interval appendectomy. We performed a single-incision laparoscopic appendectomy, and the patient was diagnosed with goblet cell carcinoid(GCC)based on the postoperative pathological examination. Since GCC is considered a high-grade tumor, we performed a laparoscopic ileocolic resection with D3 lymphadenectomy. There was no residual disease or lymph node metastasis detected in the resected specimen. Patients with advanced GCC typically have poor prognosis, because GCC is characterized by peritoneal dissemination and lymph node metastasis. However, our findings suggested that an additional laparoscopic surgery could be one of the curative and safe treatment options for selected pa- tients with GCC.

The patient was a 49-year-old man with persistent fever since the introduction of hemodialysis(HD). Vomiting and abdominal swelling appeared 4 months after initiating hemodialysis. Computed tomography(CT)scan revealed a tumor measuring 9 cm, and disorders of passage from the jejunum. Surgery was performed, and resection was impossible because of peritoneal dissemination. Histopathological examination of the disseminated nodes suggested an undifferentiated pleomorphic sarcoma. Postoperatively, drainage from the gastric fistula was approximately 2,000mL/day. Chemotherapy was considered impossible because of HD, and palliative therapy was selected. However, the volume of drainage from the gastric fistula gradually decreased, and the disorders of passage reduced. CT scan confirmed marked reduction in the size of the intraperitoneal tumor and its subsequent disappearance. At the 2-year-and-5-month postoperative follow-up, no relapses were observed, and the course had been uneventful. Undifferentiated pleomorphic sarcomas develop in the soft tissue of adults and have a poor prognosis. However, mesenteric development is rare. Total tumorectomy is the first choice of treatment. A consensus on the usefulness of chemotherapy or radiotherapy has not been reached. Furthermore, no studies have reported spontaneous tumor disappearance in the absence of treatment. Here, we report a case of minor undifferentiated primary mesenteric sarcoma and its spontaneous disappearance and review the literature.

We present the case of a 69-year-old man who was diagnosed with ascending colon cancer. Preoperative CT revealed 2 advanced esophageal cancers, both at T4; thus, a diagnosis of esophageal cancer(Ut-Ce, cT4b[Tr]N2M0, Stage ⅣA/Mt, cT4b[Lt-Br]N2M0, Stage ⅣA)was made. The patient received chemotherapy(DTX/CDDP/5-FU), and as the second-line treatment, he received chemoradiotherapy(40 Gy with DTX/CDDP/5-FU). We performed transthoracoabdominal esophagectomy, laryngeal preservation with tracheal resection, 3-field lymph node dissection, posterior mediastinal gastric tube reconstruction, mediastinal tracheostomy, and pectoralis major myocutaneous flap filling. He had an anterior chest wall subcutaneous abscess without respiratory complications. Pathological examination indicated a complete response. Two months after the surgery for esophageal cancer, radical surgery was performed for the colon cancer. Fifty-five months after esophagus cancer surgery, no recurrence was observed.

A 69-year-old male complained of gross hematuria. Cystoscopy revealed a papillary pedunculated tumor. The tumor was approximately 4 cm in length, and mimicked an inverted papilloma with a small stalk and smooth surface, located on the bladder trigone. Transurethral resection of the bladder tumor was performed, and the tumor was resected en bloc. Histopathological examination revealed thick and irregular epithelial cords. Immunohistochemically, Ki-67 labeling index was 5%, p40 and CK7 were positive, and CK20 was negative. Then, this tumor was diagnosed as inverted variant of urothelial carcinoma. Even when gross appearance is compatible with inverted papilloma, pathological and immunohistochemical examinations are essential for accurate diagnosis of inverted bladder tumor. No recurrence was observed by cystoscopy 13 months after the resection.

A 65-year-old woman with type Ⅱ diabetes and unstable angina presented with chest pain due to in-stent restenosis. Her regular medication comprised an sodium-glucose co-transporter( SGLT) 2 inhibitor. Because of unstable hemodynamic status, semi-emergency coronary artery bypass grafting (CABG) was performed. Postoperatively, the cardiac and hemodynamic status stabilized, but there was progression of metabolic acidosis. Based on the presence of massive urinary ketone bodies without hyper glycosuria, the patient was diagnosed with euglycemic diabetic ketoacidosis( DKA) caused by an SGLT2 inhibitor. Ketoacidosis without elevated blood glucose( i.e., euglycemic DKA) has been reported to be associated with intake of an SGLT2 inhibitor, which promoted glucose excretion in the urine. Our patient developed euglycemic DKA due to the progression of myocardial ischemia and surgical stress. Guidelines in other countries have stipulated that SGLT2 inhibitor should be stopped 24 hours preoperatively. In our case, euglycemic DKA occurred even when the SGLT2 inhibitor was stopped for more than 24 hours preoperatively. Further studies on the withdrawal of an SGLT2 inhibitor in the appropriate perioperative period are required.

Although many patients with terminal cancers desire to be cared for at home, frequently, such patients cannot be shifted to home care due to their unstable symptoms. In severe cases, emergency hospitalizations may be frequently required after introducinghome medical care. We report a case of makinghome medical care difficult due to repeated emergency hospitalizations despite of the patient's deep desire. Interviews were conducted with both the oncologist in charge of the case and a home physician, and their viewpoints were compared. For patients and their families to achieve desired livingconditions, it was considered necessary to give supportive medical care that meet their desires until the end of their lives as mutual viewpoints are taken in a good balance.

The patient, a woman in her 70s, was diagnosed with occlusive ileus caused by sigmoid colon cancer.She underwent transanal stent placement to release the occlusion.Subsequent detailed testing revealed a 70×60mm mass on the dorsal side of the pancreas and PET-CT indicated an SUVmax 18.2 FDG uptake. EUS-FNA was performed twice.However, the mass was unable to be definitively diagnosed.The patient was then referred to our hospital.She underwent laparoscopic sigmoid colectomy and laparoscopic biopsy of the mass for sigmoid colon cancer.The patient progressed well postoperatively and was discharged home on postoperative day 9.The postoperative diagnosis was colon cancer(S, Type 2, 58×50 mm, tub2, pT4a [SE], pN1, Stage Ⅲa)and the biopsied mass was found to be a nodal marginal zone B-cell lymphoma according to histopathological testing.After undergoing chemotherapy at our hematology department, she has experienced no recurrence.

We report a rare case of an unruptured cerebral aneurysm in the left distal middle cerebral artery(MCA). A 76-year-old woman was referred to our department for unruptured cerebral aneurysms detected incidentally by magnetic resonance angiography. A left carotid angiogram revealed a saccular aneurysm arising in an arterial trunk unrelated to the branching zone of the distal MCA. The patient underwent an operation for trapping and excision of the saccular aneurysm in the distal MCA followed by end-to-end anastomosis. Histological analysis revealed an aneurysmally-dilated artery exhibiting thickened fibrous intima with foci of calcification and fragmented internal elastic lamina. Neither dissection nor infection were observed. The histological findings suggested that the aneurysm in this case was associated with arteriosclerotic change. Considering the medical history of the patient, we conclude that aging and hypertension are factors of the development of the cerebral aneurysm in our case, although the aneurysm is located in the distal MCA in which it is considered to low hemodynamic stress. We report this extremely rare case with a literature review.

The concept of "watershed shift"(WS)has been proposed as a cause of the ischemic complications following a superficial temporal artery-middle cerebral artery(STA-MCA)bypass operation performed for the management of moyamoya disease. Previous reports have observed that only 1.2-5.7% of the patients who underwent a bypass operation for the management of moyamoya disease developed cerebral infarction secondary to the WS phenomenon. To date, the WS phenomenon has not been objectively proven on imaging studies. We describe a 39-year-old woman who presented with right facial palsy and aphasia. Magnetic resonance imaging revealed cerebral infarction in the left frontal lobe secondary to moyamoya disease. Three days after undergoing the left STA-MCA bypass procedure, she showed deterioration in aphasia secondary to the occurrence of cerebral hyperperfusion syndrome(CHPS). Diffusion-weighted imaging(DWI)performed on postoperative day(POD)1 and 5 showed no area of high signal intensity. DWI performed on POD 8 showed an area of high signal intensity in the deep white matter of the left parietal lobe outside the range of the craniotomy. Postoperative fusion images of computed tomography angiography and DWI performed on POD 8 showed that the blood flow through the MCA from the bypass graft and that through the posterior cerebral artery crossed each other at the surface of the subcortical infarction. In the present case, the WS could be directly confirmed on imaging studies, and the cerebral infarction may have occurred secondary to WS concomitant with CHPS. Clinicians need to be aware of the WS phenomenon even after performing a direct bypass to treat adults with moyamoya disease.

In Japan, school lunches are provided to elementary and secondary student, not only for ensuring the intake of well-balanced and nutritious meal, but also hoping to improve their dietary habits. In this article, the authors review the effects of a school lunch program on the bone mass and dietary habits. The school lunch program was divided into 3 groups:a group provided with a complete school lunch, a group provided with only milk supplements, and a group provided with no supplement. The calcaneal bone mass was significantly higher in both primary and the junior high-school students given complete lunches compared with that in the other groups. Moreover, the intake of milk and milk products besides school lunches was more frequent in the groups that received complete lunches. The results suggest that the school lunch program, particularly that providing complete lunches, contributed to increasing the bone mass and improving the dietary habits.

In this report, we present a short review of applications of time series analysis, which consists of spectral analysis based on the maximum entropy method in the frequency domain and the least squares method in the time domain, to the incidence data of infectious diseases. This report consists of three parts. First, we present our results obtained by collaborative research on infectious disease epidemics with Chinese, Indian, Filipino and North European research organizations. Second, we present the results obtained with the Japanese infectious disease surveillance data and the time series numerically generated from a mathematical model, called the susceptible/exposed/infectious/recovered (SEIR) model. Third, we present an application of the time series analysis to pathologic tissues to examine the usefulness of time series analysis for investigating the spatial pattern of pathologic tissue. It is anticipated that time series analysis will become a useful tool for investigating not only infectious disease surveillance data but also immunological and genetic tests.

Purpose: A multi-institutional study was performed to identify the impact of different independent dose verification programs on independent dose verification software program., Methods: Data for 1,543 treatment fields were collected in three institutions. RADCALC and Simple MU Analysis (Simple MU) using the Clarkson-based algorithm were used. RADCALC needs the input of radiological path length (RPL) from radiotherapy treatment planning systems (RTPSs) (Eclipse or Pinnacle 3 ). The Simple MU computes the RPL using CT images independently from the RTPSs. Ion-chamber measurements were performed for commissioning the two programs and the RTPSs. Next, the results of the two programs were compared to the RTPSs obtained in the clinically-approved plans in all three institutions., Results: The commissioning results showed ±1.5% variation in the ion-chamber measurements and there was slight difference between the institutions. The RADCALC (0.9±2.2%) and the Simple MU (1.7±2.1%) results showed a slight systematic difference. Pinnacle 3 computed longer RPLs because it used CT-physical density tables. Thus, there was an impact on the accuracy in the treatment plans involving bone and other high-density materials., Conclusion: Dose calculation algorithms in different dose verification programs provided similar results. However, care must be taken because different RPL calculation methods in the RTPSs may affect dose difference between different independent dose verification programs by 1%.

Long-term practical on-site training, based on the Model Core Curriculum for Pharmaceutical Education, is a core program of the 6-year course of pharmaceutical education, introduced in Japan in 2010. In particular, medication counseling in practical training in 5th-year provides valuable opportunities for communication with real patients rather than simulated patients (SPs). However, it can also cause anxiety in 4th-year students before practical training. To address such concerns, upperclassmen (5th- and 6th-year students), who have already completed practical training, constructed and conducted a new educational program for medication counseling practice in preclinical training based on their experiences. They also developed case scenarios and played the role of patients themselves to create more realistic clinical settings. Advice from professional SPs was also provided. The 5-step program is composed of 1st counseling, 1st small group discussion (SGD) for improving counseling, 2nd revised counseling based on the 1st SGD, 2nd SGD, and development of a counseling plan and presentation. Educational effects of the program were evaluated by questionnaire survey after preclinical training in 4th-year students and after their practical training in 5th-year students. This new program, the Advanced Medication Counseling Practice, was found to be useful to reduce anxiety about communication with patients among 4th-year students (about 90%). Even after their practical training in 5th-year, they still appreciated usefulness of this program (about 80%). This program is still valued 4 years after its development. We developed the Advanced Medication Counseling Practice in preclinical training for junior students by senior students.

Bangladesh is considered as a high-risk country for emerging infectious diseases because of its high population density, poverty, and unhygienic conditions. Although control efforts have primarily been focused on major infectious diseases such as diarrheal diseases, tuberculosis, malaria, and HIV infection, the prevalence and impact of many local or minor infectious diseases are still unclarified in this country. In this review, we present our recent experience and outcomes of collaborative research on puerperal infection (PI), which is a poorly defined infectious disease in Bangladesh. PI is the most common complication during the perinatal period in developing countries. We investigated the incidence of individual species of aerobic bacteria causing PIs and their drug resistance, and the genetic traits of isolates during the two-year period (2010-2012). The common species of isolates from patients with PIs were Escherichia coli, Enterococcus faecalis, Staphylococcus haemolyticus, Proteus mirabilis, Staphylococcus aureus, and Klebsiella pneumoniae. A remarkable finding was the high rates of resistance to cephalosporins among Gram-negative bacteria harboring extended-spectrum beta-lactamase genes, which were associated with carbapenem resistance in a few isolates. This study defined the importance of control of antimicrobial resistance in Bangladesh, and provided suggestions for the future direction of collaborative research on infectious diseases in Bangladesh.

[Objectives and Materials] Based on the tuber- culosis (TB) surveillance database, the incidence rates of TB infection and active disease among healthcare workers were observed for female nurses and male doctors in 2010 in comparison with those of the general population. [Results] The relative risk (RR) of active TB among female nurses aged 20-69 years was 4.86 (95% confidence interval: 4.31-5.45) for 2010, which has increased from 2.30 observed in 1987-1997. The RR was highest for nurses aged 20-29 years at 8.84 and declined with age until 3.60 for those aged 50-59 years that was still significantly higher than 1. For male doctors the RR was significantly higher than 1 only for those aged 39 years or younger. The rates of those who were -indicated for treatment of latent TB infection (LTBI) were clearly higher among healthcare workers; for female nurses the RR was 32.7 (95% CI: 30.5-35.0), ranging from the highest level of 62.8 among those aged 20-29 years down to 11.6 for those aged 60-69 years. For male doctors also, the RR was high at 9.7 (7.9- 11.7) for 20-69 years, ranging from 14.5 for those aged 20- 29 years down to 5.3 for those aged 60-69 years. [Discussion] TB cases of nurses and doctors were more likely to be detected by the active case finding measures such as periodic screening and contact investigations than cases in the general population, which indicates the current effort of addressing the occupational exposure in the healthcare set- tings. The high level of risk of TB disease as Iwell as LTBI among healthcare professions and its possibly increasing trend as. seen in female nurses warrants further strengthening of monitoring of the problem and overall countermeasures in their workplaces.

Acquired von Willebrand syndrome (AvWS) is a rare bleeding disorder with laboratory findings resembling those of congenital von Willebrand disease. AvWS usually occurs in association with a variety of underlying disorders, such as lymphoproliferative disease or cardiovascular disease, but autoimmune AvWS is very rare. We now describe the case of a 42-year-old woman with autoimmune AvWS with concurrent antiphospholipid syndrome (APS). The patient was suffering from epistaxis and menorrhagia from few years prior to referral. She was referred to our hospital because of Activated Partial Thromboplastin Time (APTT) prolongation. Autoimmune AvWS was diagnosed as hemostatic and immunological analyses showed very low (<6%) levels of vWF ristocetin cofactor activity, low (6%) levels of vWF antigen and the presence of anti-vWF antibodies (IgG1 and IgG2) as well as antiphospholipid antibodies. Steroid therapy led to prompt AvWS remission, but deep vein thrombosis occurred in the left leg, on day 36 and APS was diagnosed. A combination of steroid and anti-coagulant was given for approximately 3 years. Thrombosis has not recurred; but AvWS re-exacerbated with steroid tapering. This is the first case report of autoimmune AvWS concurrent with APS, and the long-term disease course described here can be beneficial to clinicians.

In the malignant tumors in women, uterine cervical cancer, endometrial cancer, ovarian cancer, and breast cancer are representative diseases. The cancer treatment is classified roughly into an operation, medical treatment, and radiation therapy and has an extremely big influence on ovarian function. With the improvement in survival of cancer patients, the importance of the health care for the cancer survivors increases. It is necessary to prevent the onset of the osteoporotic fractures to maintain QOL. This paper describes the action that the malignant tumors of the women affect bone metabolism mainly from the viewpoint of ovarian function.

We report a case of a 23-year-old womanwho developed pulmonary embolism(PE)during chemotherapy for advanced gastric cancer following total gastrectomy(R1). She presented with type 4 gastric cancer with peritoneal dissemination and positive washing cytology. Palliative total gastrectomy was performed(R1)and first-line chemotherapy with S-1(80mg/m2, days 1 to 21) plus CDDP(60mg/m2, day 8)(SP; every 35 days)was administered. PE occurred on day 15 of the 3rd courses of SP. Computed tomography(CT)revealed massive PE in both the pulmonary arteries, and ultrasonography indicated an increase in right-sided pressure. Thrombolysis using urokinase and heparin was performed immediately, and she recovered after 10 days in intensive care. Dehydration caused by the adverse event, as well as nausea and the anticancer drug itself, are risk factors for DVT and PE. Risk stratification, prevention, and early treatment are very important for PE.

It has been pointed out that the motor evoked potential(MEP)with a subdural electrode is useful in the intraoperative monitoring for unruptured aneurysm surgery. However, in some cases, we experienced postoperative ischemic complications despite evaluating the motor function via MEP monitoring. Herein, we have reported the usefulness and problems of intraoperative monitoring with MEP to evaluate brain dysfunction caused by insufficiency of cerebral blood flow. Out of 279 aneurysm surgery procedures, we performed MEP monitoring in 142 cases and successfully recorded in 126 cases. We compared the ischemic complication rate of the group for which MEP was monitored with that of the group for which MEP was not monitored. The whole ischemic complication rate was decreased in the group that underwent MEP monitoring. Thus, it was suggested that MEP monitoring was useful for avoiding ischemic complications. In internal carotid artery aneurysms, the amplitude of MEP changed and recovered in 2 cases and disappeared in one case. In anterior cerebral artery aneurysms, the amplitude of MEP changed and recovered in 2 cases. In middle cerebral artery aneurysms, the amplitude of MEP changed and recovered in 5 cases. We could avoid ischemic complications by intraoperative MEP monitoring in many cases. However, in some cases, we found ischemic complications that were not detected by MEP monitoring with a subdural electrode. In these cases, transcranial stimulation in combination with subdural electrode might be effective in avoiding ischemic complications that might occur after dural closure.

Purpose: To determine the characteristics of 50 cases of pituitary tumor., Methods: The medical records of 50 cases of pituitary tumor found in glaucoma patients treated between June 2013 and June 2014 were reviewed., Results: There were 37 women and 13 men whose average age was 55.7 years with a range of 24 to 79 years. The glaucoma was unilateral in 19 and bilateral in 31. The pituitary tumors were classified as Rathke's Cleft Cyst (RCC) in 38 cases (76%), RCC with Cushing disease in 5 (10%), adenoma in 4 (8%), adenoma + growth hormone (GH) producing tumors in 2 (4%), and RCC with adenoma in 1 (2%). Of the 50 patients, 23 were treated by surgery (46%), 2 (4%) by hormone supplement therapy, 2 (4%) rejected therapy, and 23 (46%) were followed without treatment. The visual field defects corresponded with typical pituitary visual field defects in 26 (52%) cases, with that typical of unilateral glaucoma in 6 (23%), and with that typical of bilateral glaucoma in 20 (77%) cases. The major symptom was headaches in 24 (48%), headache with dizziness in 10 (20%), dizziness in only 8 (16%), and no complaints in 8 (16%)., Conclusions: Fifty patients diagnosed with glaucoma had concurrent pituitary tumors. Special attention must be paid to glaucoma patients who complain of headaches with and without dizziness.

We reported the evaluations of the carcinogenicity of fluoro-edinite, silicon carbide, and carbon nanotubes performed by IARC working group in October 2014. For carbon nanotubes (CNTs), multi-walled carbon nanotube (MWCNT)-7 was classified as Group 2B, and MWCNTs without MWCNT-7 and single-walled carbon nanotubes (SWCNTs) were classified as not classifiable in terms of their carcinogenicity to humans. There is sufficient evidence of carcinogenicity for MWCNT-7 in experimental animals, limited evidence for other MWCNTs, and inadequate evidence for SWCNTs. The mechanic evidence for CNTs was not strong. Fluoro-edinite was classified as carcinogenic to humans (Group 1) on the basis of sufficient evidence of carcinogenicity to humans and experimental animals. Silicon carbide was classified into silicon carbide fibers and whiskers. Silicon carbide fibers were evaluated as possibly carcinogenic to humans (Group 2B) on the basis of limited evidence of carcinogenicity to humans. Silicon carbide whiskers were evaluated as probably carcinogenic to humans (Group 2A) on the basis of sufficient evidence of carcinogenicity to experimental animals and the similarity of their physicochemical properties to those of asbestos in terms of the mechanism of carcinogenicity. We report the process of progression in meeting and discuss how to determine the evidence and the evaluation of the carcinogenicity of the three materials.

With the development of medicine, the field of clinical laboratory medicine evolves rapidly, and it will be more specialized in the near future. Medical technologists are required to hone their skills and knowledge, in order to keep up with the evolution. In recent years, board certifications by several medical societies are considered to indicate the skills of medical technologists. The number of board-certified medical technologists in populated areas such as Tokyo, Kanagawa, Osaka, and Fukuoka is greater than in less populated areas such as Kyusyu and Tohoku. The rate of certified medical technologists among prefectures is the highest in Mie (10.1%), followed by Nagasaki (8.8%). Tokyo, Ishikawa, Kyoto, and Osaka have acquisition rates greater than 7%. In contrast, prefectures of Miyazaki, Kumamoto, Yamanashi, and Akita have low acquisition rates of less than 4%. Being certified is not only an opportunity for personal career advancement, but also a chance to improve the laboratory. More technologists are being certified in our laboratory, and we are encouraging a future increase in their number. However, there are some problems to be overcome. Assignment of competent staff and long-term and premeditated rotation are considered to be important for staff to find the work rewarding, and the laboratory to be trusted by physicians.

We report a case of an oral penetrating injury caused by a toothbrush in a 4-year-old 17-kg boy. The toothbrush was lodged in the right cervical region through the oral cavity, and emergency surgery for removal was planned under general anesthesia. Although mask ventilation was not possible because of the protruding toothbrush handle, awake nasotracheal intubation was successfully performed with a fiber-scope and intravenous fentanyl 25 μg. We conclude that appropriate analgesics could facilitate awake intubation in pediatric patients.

Several studies have shown the predictive value of elevated serum alkaline phosphatase (ALP) level in multiple myeloma (MM) patients treated with bortezomib (BTZ). We assessed the relationship between changes in ALP levels during treatment and response. Thirty patients treated with BTZ in our hospital were analyzed retrospectively. Of the patients analyzed, 12 were male, median age was 62 years (42-86), and 11 had a history of prior chemotherapy. Eighteen patients were treated with BTZ alone or in combination with dexamethasone, while the others were treated with a combination regimen employing an alkylating agent. Seven patients had undergone autologous stem cell transplantation following BTZ therapy. Ten of 28 patients showed ALP elevation of 25% or more from the baseline at 3 weeks, and 14 of the 28 had this finding at 6 weeks. Four of 5 patients who had achieved VGPR or more showed ALP elevation of 25% or more at 3 weeks, and all five had this finding by 6 weeks. No patient without ALP elevation achieved VGPR or a better response. ALP elevation exceeding 25% from the baseline by day 42 is significantly associated with a treatment response better than VGPR (p=0.019). In conclusion, ALP elevation during BTZ treatment is a valuable prognostic marker.