Search

Objective: We aimed to investigate the characteristics and operative results of elderly patients with cervical spondylotic myelopathy(aged ≧80 years)treated using the posterior approach., Methods: Between April 2010 and December 2018, 21 patients aged ≧80 years(older group:8 men and 13 women;age range, 80-90 years)who underwent laminoplasty were reviewed and compared with 23 patients aged <80 years(younger group;13 men and 10 women;age range, 42-79 years)who underwent laminoplasty. The following data were obtained from chart reviews:age;sex;cervical canal stenosis level;time to operation;symptoms(e.g., gait disturbance);comorbidities(hypertension, diabetes mellitus, cancer, heart disease, ischemic cerebrovascular disease, and lumbar canal stenosis);antithrombotic drug use;cardiac, pulmonary, and renal functions;operative time;volume of blood loss during the operation;postoperative delirium;and follow-up period. Neurological deficits before and after the surgery were assessed using the neurosurgical cervical spine scale(NCSS). Data were statistically analyzed, and p-values <0.05 were considered statistically significant., Results: The operative time, symptoms(hypertension), renal function, and preoperative NCSS score were significantly different between the older and younger groups. Meanwhile, most variables showed no significant differences between the groups. Although the preoperative NCSS score was lower in the older group, there was no significant difference in the degree of improvement in the NCSS score after surgery., Conclusions: The findings of this study suggest that we should not hesitate to perform surgery for cervical spondylotic myelopathy in elderly patients with favorable cardiorespiratory function.

Aim: Support for elderly patients using insulin to continue self-injection safely is required for clinical settings. The aim of this study was 1) to clarify the actual state of self-injection procedures for elderly people injecting insulin and 2) to verify whether or not the injection procedures can be improved by nurses' medical treatment instructions., Subjects and Methods: The subjects were outpatients at an educational facility certified by the Japan Diabetes Society. Basic clinical characteristics, the Mini-Cog cognitive function test, basic ADL and instrumental ADL, and 24 items of the self-injection procedure were evaluated by nurses. After receiving a 30-minute face-to-face session of individual instructions from trained nurses two or more times, the injection procedure was re-evaluated., Results: Of the 63 study subjects, 10 were injecting insulin with the support of others (supported injection group). The median age in the self-injection group was 72 years old, while that in the supported injection group was 82 years old. The supported injection group was older, the female ratio higher, and the Mini-Cog and ADL indices lower than in the self-injection group (p <0.05). The median history of the use of insulin was over 10 years in both groups. In the self-injection group, the degree of proficiency with the injection technique was significantly improved after receiving the instructions (p <0.05). The biggest improvement was in response to the question, "Do you know that you need to shift the site of injections?", which doubled (p <0.05). The correct answer rate for "Do you know the name of your insulin formulation?" was less than half, and it remained unchanged even after receiving instructions. In the supported injection group, 90% had a Mini-Cog of ≤2 points, but 6 subjects (60%) were able to perform an injection by themselves with others supporting the adjustments made to the amount of insulin., Conclusions: The self-injection technique improved significantly, even in elderly people, following the delivery of medical treatment instructions by nurses, and the item with the highest improvement effect was subjects' understanding of the need to shift the injection site. Our study showed that even in elderly people with cognitive dysfunction who are performing injections with the support of others, some of the injection procedures were retained by relying on procedural memory acquired in the past.

Drop foot is associated with various diseases, such as peripheral nerve disease, lumbar degenerative disease, metabolic disease, and endocrine disease. Among lumbar degenerative diseases, lumbar disc herniation and lumbar canal stenosis are most commonly reported. We report the surgical outcomes of patients with drop foot caused by lumbar degenerative diseases. Between 2008 and 2018, we encountered 24 cases of drop foot in patients who underwent surgery of the lumbar lesion. The mean age was 69.5 years(49-88 years). Fourteen patients were male and ten were female. The mean time interval between the onset of drop foot and surgery was 51.5 days(from 7 days to 1 year). Drop foot, as a clinically significant muscle weakness, was defined at levels of manual muscle test(MMT)3 or lower. Responsible lesions for drop foot were canal stenosis at L4/5 in 8 cases, disc herniation at L4/5 in 10 cases, disc herniation at L5/S1 in 5 cases, and far-out syndrome in 1. One case involved drop foot bilaterally. Muscle weakness improved by surgery at levels of MMT 4 or greater in 16 cases(66.7%). Six cases of complete paresis or tibialis anterior muscle atrophy preoperatively resulted in no improvement;however, neuralgia was relieved in all. Twelve of 15 cases(80%)of lumbar disc herniation and 4 of 10 cases(40%)of lumbar canal stenosis resulted in improvement. Between disc herniation and canal stenosis, the surgical success rate was not statistically different. Age and the time interval between the onset and surgery were also not significant factors of the outcome. Surgical intervention seems to be beneficial even in cases of severe muscle weakness since pain relief can be expected, which leads to improvement in gait.

A 55-year-old man presented with progressive pain and expanding swelling in his right neck. He had no history of trauma or infectious disease. The patient had undergone chiropractic manipulations once in a month and the last manipulation was done one day before the admission to our hospital. On examination by laryngeal endoscopy, a swelling was found on the posterior wall of the pharynx on the right side. The right piriform fossa was invisible. CT revealed hematoma in the posterior wall of the right oropharynx compressing the airway tract. Aneurysm-like enhanced lesion was also seen near the right common carotid artery. Ultrasound imaging revealed a fistula of approximately 1.2 mm at the posterior wall of the external carotid artery and inflow image of blood to the aneurysm of a diameter of approximately 12 mm. No dissection or stenosis of the artery was found. Jet inflow of blood into the aneurysm was confirmed by angiography. T1-weighted MR imaging revealed presence of hematoma on the posterior wall of the pharynx and the aneurysm was recognized by gadolinium-enhancement. We performed emergency surgery to remove the aneurysm while preserving the patency of the external carotid artery. The pin-hole fistula was sutured and the wall of the aneurysm was removed. Histopathological assessment of the rissue revealed pseudoaneurysm. The patient was discharged after 12 days without deficit. Progressively growing aneurysm of the external carotid artery is caused by various factors and early intervention is recommended. Although, currently, intravascular surgery is commonly indicated, direct surgery is also feasible and has advantages with regard to pathological diagnosis and complete repair of the parent artery.

Two cases of breast cancer with bilateral orbital metastases associated with intracranial metastases are presented. Case 1:A 61-year-old woman who was diagnosed with breast cancer 14 years earlier presented with rapid deterioration of visual acuity, eye pain, and limitation of left-sided extraocular motility. Magnetic resonance(MR)images showed an enhanced lesion in the left orbital apex, ethmoid sinus, and right middle fossa. The first gamma knife radiotherapy(35 Gy, 5 Fr)was performed successfully, but was followed by recurrence 18 months later in the right intraorbital, where newly formed iso-intensity masses in the extraconal compartment were found. The second gamma knife radiosurgery was performed for three masses(20 Gy). Case 2:A 35-year-old woman with breast cancer who was diagnosed 22 months earlier was treated for meningeal carcinomatosis by whole-brain radiation(30 Gy, 10 Fr)and intrathecal chemotherapy. Eight months later, swelling in both eyelids and limitation of extraocular motility developed rapidly. MR imaging revealed an infiltrating lesion in the cone with heterogenous signal that was encasing, but not infiltrating the optic nerves. The extraconal lesion extended into the soft tissue of the lower eye lid. She expired one week after diagnosis. With the increasing number of long-term survivors with breast cancer, intraorbital metastases may be found during the course of treatment for intracranial lesions. Understanding the unique clinical presentation and characteristic MR findings of this rare entity are emphasized.

A 59-year-old woman presented with high serum total protein, detected on a screening examination. Laboratory tests revealed high plasma levels of M-protein (IgG-λ), and FDG-PET/CT revealed systemic lymph node swelling and a large tumorous mass in the abdominal cavity. Bone marrow aspirates contained 8.4% plasma cells and approximately 30% abnormal small lymphocytes. A biopsy of the left supraclavicular lymph node was initially interpreted as lymphoplasmacytic lymphoma (LPL). However, chromosomal analysis of the lymph node demonstrated an unusual karyotype with t (14;18) (q32;q21). FISH analysis for the IgH-BCL2 fusion gene was positive. Furthermore, the MYD88 L265P mutation was not detected in tumor cells. Based on these findings, this case was determined to be a type of follicular lymphoma with plasmacytic differentiation. We considered that this case was an important example emphasizing the importance of karyotypic examination for lymphoma classification.

Objective: Saga University has the "Saga Forum of Environment" project conducted in collaboration with the Saga city local government. In this project, a workshop was held to study the sick building syndrome at schools. The purpose of this workshop was to evaluate indoor air pollution levels in elementary and junior high schools in Saga city., Methods: The levels of aldehydes and volatile organic compounds (VOC) were measured in 96 classrooms of the 49 schools in August. The sampling of these chemicals were performed by the passive sampler method and measured by high-performance liquid chromatograph or gas chromatograph-mass spectrometer by participants of the workshop., Results: In 40% of all classrooms, formaldehyde levels were higher than that of the standard of Japanese Ministry of Education. Relatively high levels of formaldehyde were found in some music classrooms. The origin of formaldehyde was thought to be musical instruments, furniture or wooden floors. A significant correlation was found between formaldehyde level and room temperature. The classrooms with ventilators showed lower levels of formaldehyde than those without ventilators. The levels of most VOCs except that of alpha-pinene were low., Conclusion: There is still room for improvement of air pollution in elementary and junior high schools.

A 58-year-old man with metastatic brain tumor in his right occipito-temporal region was operated, using craniectomy. He had no neurological symptoms preoperatively. The tumor was 2.5 cm in diameter with minor perifocal edema. Two days after total removal of the tumor, typical prosopagnosia appeared, in which he could not recognize his wife's face as well as faces of medical stuff. He could see them as a whole, and described them undistinguishably from each other. He used voices, movements and clothing to recognize a familiar person. His recognition and semantic knowledge of people were found to be intact and he could recognize certain parts of the face (e.g. the nose or the mouth). He could clearly see other parts of the body, the environment and other objects, in color. The prosopagnostic condition lasted for a few weeks and slowly disappeared. Prosopagnosia caused by surgical procedure has been rarely reported. Although postoperative prosopagnosia is likely to be transient, it should be recognized as a complication in occipito-temporal cortex.

A phase II study of combination therapy with gemcitabine and carboplatin was performed in 24 patients with advanced non-small cell lung cancer to evaluate the efficacy and safety of the therapy. Patients were treated at 3-week intervals with two courses or more of the regimen consisting of gemcitabine 1,000 mg/m(2) and carboplatin AUC 2 on day 1 and day 8. Response rate was 37.5% (9/24) (95% confidence interval: 18.8-59.4%). The median number of courses was 3(range 1-8). The time to progressive disease was 147 days and the median survival was 338 days. The one-year survival rate was 45.8%. The major toxicity was hematotoxicity, and >or=grade 3 neutropenia(58.3%)and thrombocytopenia (45.8%) occurred. None of >or=grade 3 non-hematotoxicities were evident, but grade 2 rash (8.3%) and fever (8.3%), nausea (4.2%), vomiting (4.2%) occurred. None of the other severe toxicities appeared. In conclusion, this combination therapy was suggested to be tolerable with a high response rate and safety, and we plan to continue testing.

A 30-year-old man developed an exopthalmus in his right eye and diplopia at upward gaze those were progressive in two days. On admission, his upper eye lid in the right eye swelled and upward gaze was limited in the right eye. CT scan showed an osteolytic lesion in the right frontorbital bone. MR imaging showed a high signal tumor in both T1- and T2-weighted imaging with sharp margin and no enhancement. Right frontal craniotomy was performed and the cystic tumor consisting of old hematoma, and soft tissue surrounding the cyst was totally removed. The orbital roof had a large defect and tumor compressed periorbita. Neither communication with the frontal sinus nor mucosa with inflammation were seen. The postoperative course was uneventfull and pathological diagnosis was cholesterol granuloma with hematoma. Orbitofrontal bone is a rare site to have cholesterol granuloma. Most of them are asymptomatic. In our case, intratumoral hemorrhage caused compression on the perioribital, leading to a progressive mass sign. Preoperative differential diagnosis from other orbital tumors, such as epidermoid and lipoma was difficult.

We report a case of a 43-year-old man treated by craniotomy for chronical subdural hematoma (CSH) due to spontaneous intracranial hypovolemia. The patient complained of sudden onset severe headache. Initial CT scan showed normal brain structure, and his headache improved with bed rest in a few days. However, MR images obtained for vertigo one month later demonstrated bilateral subdural hygroma extending to the supracerebellar space and diffuse dural enhancement after gadolinium infusion. We diagnosed bilateral subdural hygroma due to spontaneous intracranial hypovolemia, and observed him conservatively. Four months after onset, he complained of severe headache again and MR images revealed enlargement of bilateral CSH with mass effect, which had heterogenous intensity on the right convexity. We evacuated hematoma on the right by craniotomy and aspirated the left side hematoma using a burr hole. His headache improved 2 weeks after the operation with strict bed rest. The follow-up MR images showed disappearance of abnormal meningeal enhancement and improvement of brain sagging.

Medical treatment has been changing due to the recent and great progress in the molecule genetics. Gene tests are contained in the ordinary medical treatments. However, this progress in Japan has apparently thrown the general population into confusion, at least in part because of the lack of consent between inhabitants and clinicians/researchers. Some of the genetic diseases are difficult to be cured completely, although they can be diagnosed. Furthermore, genetic diseases spread the influences to other relations including their offspring. The preparation of the various genetic guidelines and the fulfillment of the genetic counseling are going to proceed to keep the human rights of the patients of the genetic diseases. A discussion of the bio-ethical problems has been developing at the same time. The necessity against the genetic service is increasing gradually. Genetic medical treatment may be a part of the genetic service. I report here the current status of "the genetic counseling and the genetic medical treatment" have been advanced in Nagasaki university hospital as an example. It is very important and expected that a proper genetic service is provided to the clients under the network of the specialists of the various fields.

In an effort to evaluate flow characteristics of the saphenous vein grafts (SVG) after coronary artery bypass grafting, we performed duplex scanning of SVG which were anastomosed to the left anterior descending artery in 12 patients, and compared those indexes with 34 internal thoracic artery grafts (ITAG). The SVG were observed with a 7.5 MHz duplex scanner through the anterior intercostal space. The diameter of the vessel, systolic peak velocity, and diastolic peak velocity were recorded in both groups, and systolic flow volume, diastolic flow volume, and velocity ratio were calculated. The systolic and diastolic peak velocity of SVG were predominantly lower than ITAG. No difference in the diameter and flow ratio could not be demonstrated between 2 groups. The flow volume of SVG were also predominantly lower than that of ITAG throughout cardiac cycle. This study reveals that advanced stenotic change were caused in the SVG group and suggest the occurrence of vein grafts disease long after coronary artery bypass grafting.

Chondroma is a benign cartilaginous tumor and fairly rare in the spine. A case of chondroma in the lumbar spine is presented. A male at age 66 was suffered from progressive low back pain associated with hypesthesia in his right leg. Radiographic examination showed an extradural mass in the dorsal part of spinal canal at L 5 level. No osteolytic change was noted by CT scan. MRI showed iso-intensity with marginal enhancement on T 1-weighted images and heterogeneous intensity on T 2-weighted image. The mass was totally removed by laminectomy and pathohistologically diagnosed as chondroma. Postoperative course was uneventful and the symptoms disappeared completely. One of the origin of chondroma is thought to be metaplasia of the connective tissue in contact with spine. This is why no pathological change was found in bone adjacent to the tumor. Careful preoperative diagnosis and total removal of the tumor is important since malignant transformation may happen in chondroma.

A phase II study of a combination therapy with vinorelbine (Navelbine) plus cisplatin was performed using 27 patients with advanced non-small cell lung cancer, to evaluate the efficacy and safety of this therapy. Patients were treated, at 3-week intervals, with two or more courses of a regimen consisting of vinorelbine 25 mg/m2 (days 1, 8) and cisplatin 80 mg/m2 (day 1). The response rate was 48.1% (13/27) (95% confidence interval: 28.7-68.1%). The median number of treatment courses was 2.6. The major toxicity was hematological: 74% of patients had neutropenia of grade 3 or higher that subsided rapidly upon administration of a granulocyte-colony stimulating factor. Non-hematological toxicities were mild, of grade 2 or less: the main symptom was nausea/vomiting (62%), although constipation, eruption, anorexia, peripheral nerve disorders, diarrhea, fever, and other conditions were also observed. In conclusion, the high response rate and good tolerance to this combination therapy warrants further study.

Doppler echocardiography has several advantages such as frequent use, noninvasive approach, and physiological evaluation. Supine bicycle exercise testing was conducted for 30 patients undergoing CABG with LITA to LAD. Doppler echocardiography studies were performed before and after exercise to observe the change. On the basis of the angiographic data, patients were divided into two groups: 27 patients with a patent LITA graft, 3 patients with mildly stenosed LITA graft. In the patients who had patent grafts, diastolic flow velocity were increased higher than systolic after exercise. In the stenotic group, the flow pattern was changed to further systolic one. Doppler echocardiography during exercise is thought to be a reliable method to assess the LITA flow.

A 60-year-old man, who had undergone implantation of a transvenous pacemaker system on the left chest wall for sick sinus syndrome 19 years ago, was admitted because of endocarditis with septicemia and lung abscess 2 months after reimplantation of the generator. His blood culture revealed Staphylococcus aureus. Following debridement of the infected pacemaker pocket and antibiotics therapy, we tried to remove the pacemaker system under cardiopulmonary bypass 1 month after admission. In intraoperative inspection, the electrodes had become firmly encased with fibrous tissue within the tricuspid valve and the right ventricle. After the operation, antibiotic therapy was performed for 4 weeks. His postoperative course was uneventful. Patients with pacemaker infection should undergo aggressive total removal of the pacemaker system, particularly incase with endocarditis and bacteremia.

A 70-year-old female was admitted to our unit with chief complaints of dyspnea on effort and angina pectoris. She had suffered from chronic bronchitis. Chest CT scan demonstrated a giant arch aneurysm which strongly attached to the left anterior chest wall. Coronary angiogram showed two vessels disease. She successfully underwent coronary artery bypass grafting and total arch replacement under selective cerebral perfusion. She needed long respiratory care because of her pulmonary dysfunction. But she could wean from the ventilator under intensive respiratory care on 46th postoperative days and was discharged on foot.

A 71-year-old male was admitted to our hospital with a chief complaint of back pain. Chest CT scan showed so-called Stanford type A thrombosed aortic dissection. Aortography revealed no ulcer like projection. At first, conservative treatment was carried out. But about two hours later, he had another back pain. Repeat chest CT scan demonstrated an enlarged dissecting lumen, necessitating emergent graft replacement. Postoperative course was uneventful and he was discharged on the 33rd postoperative days.

Recent laboratory information systems have usually adopted a client server system. Computing tools which can provide easy access to a database using simple language are now strongly needed. These functions are provided in an End User Computing (EUC) system. An EUC is defined as follows: 1) General end users can easily access the database of the laboraotry system and extract objective data stored in database. 2) The extracted data will be easily converted to files that can be processed by commercially available software. In this paper, we demonstrate the examples how to use the EUC for a quality assurance system and analyses of laboratory workflow. In the case of quality assurance, we demonstrate the setting of reference intervals from stored laboratory data concerning health care examination programs at our university. Secondly, we developed a system of monitoring quality control data, and set parameters for delta checking and actual zone QC method. We can estimate and design an outline of laboratory workflow from extraction of the time currently required for each task. We can measure the turn-around time for laboratory testing and rate of requests for laboratory tests received from physicians via order entry system. Moreover, we can estimate and simulate the waiting time and time required for analyses by outpatient clinics. These time monitoring systems reflect the design of laboratory workflow such as the labor and equipment time required in laboratory work. These uses of laboratory data are currently expanding further and further in the fields of education and laboratory research. We believe that information technology will facilitate future advances of laboratory medicine.

We have devised a 'Fold Plication Method', which helps ensure safe and simple lung volume reduction surgery (LVRS) for pulmonary emphysema and prevent air leakage from pulmonary stumps, which is most crucial problem, in addition to postoperative interstitial pneumonia that is occasionally caused by the use of the bovine pericardium. We performed LVRS on seven patients with the disease, using this method and the thoracoscopic surgery, which is based on the 'Two Windows Method' we had previously developed. The operation was performed without observable bleeding within approximately one hour for all patients, who then recovered favorably.

We have encountered 31 cases of intraorbital tumors at the Kobe University Hospital between 1971 and 1996. We reviewed those cases taking into account the surgical approaches used, the removability of the tumors and functional outcome. Before 1991, frontal or fronto-temporal craniotomy had been mostly used whereas the fronto-orbito-zygomatic approach or fronto-orbital approach has been used only since 1992. After introduction of these approaches, functional outcome was significantly improved. Most of the tumors have been successfully removed totally. In particular, this approach is thought to be useful for tumors located in the deep portion of the orbit and for tumors extending intracranially. In addition, removal of the anterior clinoid process and the opening of the optic canal as well as the superior orbital fissure provides a wider operative view and enables the transposition of the optic nerve safely.

We present a case with the traumatic extracranial internal carotid artery dissecting aneurysm. A 21-year-old man was involved in a motorcycle accident, resulting in multiple injuries but no apparent head and neck injuries. Head CT was normal on his admission. He was discharged from his local hospital 3 weeks after the accident without any neurological deficits. Five weeks after the accident, he suddenly presented with a motor aphasia and a right hemiparesis. CT and MRI showed infarctions in the left para-Sylvian and the left angular areas. Angiography showed a left extracranial carotid artery dissecting aneurysm at the level of C1 vertebral arch. The patient was initially managed by an anticoagulant agent, but he suffered from another transient ischemic attack due to distal embolism from the aneurysm. Balloon occlusion test of the left ICA was performed under monitoring EEG, SEP. Mean stump pressure (MSP) revealed 60 mmHg. and MSP/Mean systematic blood pressure revealed 67%. We judged that the left ICA ligation was a safe method to treat this patient, however, considering the patient's age and the side of the lesion, left STA-MICA bypass and ligation of the left ICA were carried out in one stage. Postoperatively, the patient did not show any cerebral ischemic complications and angiography showed disappearance of the aneurysm and patency of the bypass. The left MCA territories were filled well by cross circulation and the bypass.