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A 67-year-old woman with past medical history of chronic myelomonocytic leukemia (CMML) presented with a chief complaint of headache, diplopia, and hearing impairment in the right ear. Examination revealed impaired ocular movement in the left eye and sensorineural hearing loss in the right ear. Cerebrospinal fluid analysis showed increased cell count and protein, and MRI showed contrast enhancement of hypertrophic dura mater. Since there were no other abnormalities which would have been a cause of hypertrophic pachymeningitis, it was considered as systemic autoimmune/inflammatory disorder (SAID) associated with CMML. Treatment with steroid, cyclophosphamide, and methotrexate led to improvement of the symptoms. SAIDs develop in up to 25% of patients with myelodysplastic syndromes (MDS) or CMML, which may be the only symptoms of MDS/CMML. As a phenotype of SAIDs, systemic vasculitis, connective tissue diseases, and neutrophilic diseases are frequently reported; however, isolated involvement of central nerve system is rarely reported. To our knowledge, this is the first report of hypertrophic pachymeningitis as SAID associated with CMML. To clarify the pathogenesis of neurologic involvement of SAIDs, accumulation of cases is necessary.

We reported our long-term results of valve sparing aortic root replacement (VSRR) and aortic cusp repair for aortic regurgitation( AR) were satisfactory. Three hundred twenty-seven patients had VSRR, and 164 patients of them had aortic cusp repair for prolapse. At 10 years after the operation, the overall survival was 91.5%, the freedom from more than mild recurrent AR was 71.2%, and the freedom from aortic valve reoperation was 82.0%. As for the aortic cusp repair technique, there was no significant difference in the mid-term results of the recurrent AR and reoperation for the aortic valve between the central plication technique and the resuspension technique (two layers of continuous mattress sutures placed the entire length of the free margin of the aortic cusp). The resuspension technique might be useful for repairing the aortic cusp with prolapse. Furthermore, among the patients with acute aortic dissection, connective tissue disease, or aortitis, the long-term results of VSRR and aortic cusp repair were also satisfactory.

The patient is a 56-year-old man. He fell while playing golf and sustained a contusion on his right chest. He fell into hemorrhagic shock during surgery for a right clavicle fracture at a nearby hospital and required cardiac resuscitation. Computed tomography( CT) scan revealed left pneumothorax and right hemothorax, and a contrast-enhanced CT scan revealed a pseudoaneurysm at the brachiocephalic artery origin. He underwent surgery three weeks later. Surgery was performed through a median sternotomy and partial arch replacement (zone 2) with antegrade cerebral perfusion under moderate hypothermia. He was discharged on postoperative day 10 without significant complications.

Objectives　Though having a high salt taste threshold has been associated with hypertension, its exact determinants remains unclear. This study aimed to identify the determinants of salt taste threshold in a community-based population and to determine the relationship between salt taste thresholds and the simultaneous presence of multiple determinants.Methods　Of the 1,117 participants of the baseline survey of the Kobe study, a cohort study of healthy urban residents, aged 40-74 years, with no history of cancer or cardiovascular diseases, nor undergoing treatment for hypertension, diabetes, or dyslipidemia, was conducted. Among them, 1,116 underwent the salt taste threshold test, and urine samples were collected to determine their estimated salt intake. The salt taste threshold test was carried out using SALSAVE ® , with a salt taste threshold of 0.6% defined as normal, and that of 0.8% or more defined as high. A binomial logistic regression model was used, with high salt taste threshold as the objective variable, and life and family status, education, smoking and alcohol drinking status, intake status of salt dried fish, stress indicators, and daily salt intake (estimated from the urine sample) as the explanatory variables. A binomial logistic regression analysis was conducted, through multivariate analysis using the forced entry method, with factors influencing salt taste threshold as explanatory variables, and salt taste threshold (normal/high) as the objective variable. This analysis was performed excluding the urinary sodium-to-potassium ratio to account for multicollinearity with the estimated daily salt intake.Results　The mean age was 60.9±9.0 years for men, and 58.0±8.7 years for women. The salt taste threshold was normal in 80.9% (n=903) of the participants (73.6% [n=251] men and 84.1% [n=652] women), and high in 19.1% (n=213) of the participants (26.3% [n=90] men and 15.9% [n=123] women). Multivariate analysis revealed that smoking habits were significantly associated with a higher salt taste threshold, with an odds ratio (95% confidence interval) of 2.51 (1.33-4.74) for all participants. The odds ratio for a high salt taste threshold was 1.45 (1.03-2.03) for the top 25% estimated daily salt intake group, showing a significant association with a high salt taste threshold. In the analysis by sex, smoking habits were associated with higher salt taste thresholds, while an association with estimated daily salt intake was observed only in men.Conclusion　Smoking status and estimated daily salt intake were associated with higher salt taste thresholds in healthy urban residents.

A 78-year-old woman with a left breast cancer was examined at our institute. Ultrasonography showed 48 mm sized mass at zone C of the left breast, and left axillary lymph node swelling. Pathological examination of core needle biopsy revealed invasive ductal carcinoma and lymph node metastasis. In addition, contrast computed tomography showed 30 mm sized an hypovascular mass at pancreatic body involved the portal vein. Endoscopic ultrasound guided fine needle aspiration biopsy of the pancreas revealed adenocarcinoma. The diagnosis was synchronous double cancer including borderline resectable pancreatic body cancer and left breast cancer, and she received neoadjuvant chemotherapy consisting of gemcitabine and nab-paclitaxel. The effect of neoadjuvant chemotherapy was judged to be stable disease for breast cancer, partial response for pancreatic cancer. Then, she underwent pancreatosplenectomy with portal vein and gastroduodenal artery resection and reconstruction, left mastectomy and axillary lymph node dissection. Pathologic examination of the excised specimen revealed the diagnosis of breast cancer with osseous/cartilaginous differentiation and pancreatic moderately differentiated adenocarcinoma. She was treated with fluorouracil, epirubicin, and cyclophosphamide as adjuvant therapy, and there has been no recurrence.

A 68-year-old man with a 2-month history of progressive weakness and spontaneous pain in proximal limb muscles presented to our hospital with a dropped head. He started experiencing progressive dysphagia several days before admission. On admission, he had muscle weakness of the limbs and neck extensors with edema and induration in distal extremities. Laboratory tests showed elevation of muscle enzymes. FDG-PET/CT demonstrated multiple hypermetabolic lymph nodes, but the primary site was not identified; thus, metastatic carcinoma of unknown primary origin was considered. The patient was diagnosed with anti-nuclear matrix protein 2 antibody-positive paraneoplastic myopathy based on serum tests. Histological findings of the left biceps brachii muscle biopsy revealed severe variation in fiber size and perifascicular myofiber atrophy. Myofibers exhibited myxovirus resistance protein A expression predominantly in the perifascicular region. Following intravenous methylprednisolone pulse therapy and intravenous immunoglobulin, the patient's muscle strength improved with normalization of muscle enzyme levels. The dropped head was considered to have resulted from the preferential involvement of neck extensors based on the observed FDG-PET/CT uptake in neck extensors.

Objective　To explore health-related and socioeconomic factors that can predict future deterioration in Psychological Distress Scale (K6) scores.Method　We conducted a baseline (2010, 2011) self-administered questionnaire survey of the Kobe Orthopedic and Biomedical Epidemiological study (KOBE study) involving 1,117 participants who had no previous history of cancer or cardiovascular diseases and were not under treatment for hypertension, diabetes, or dyslipidemia. We used the Japanese K6 as an indicator of stress and defined K6≧5 points as a high-stress group and K6<5 points as a low-stress group. A four-year follow-up survey (2014, 2015) was conducted on 1,004 people (follow-up rate of 90%). We excluded 39 participants with missing values, and 185 people whose K6 score was higher than 5 points at baseline. A final total of 780 participants' scores were examined for: gender, age, living situation, physical activity level, average sleep time, as well as the K6 score, the Japanese Hearing Handicap Inventory for Elderly (HHIE-S), and the Japanese Oswestry Disability Index (ODI). We conducted a logistic regression analysis using K6≧5 points at the four-year follow-up survey as the dependent variable and each factor at the baseline survey as the independent variable.Results　Of the 780 subjects analyzed, 132 (16.9%) were highly stressed (K6≧5 points) at the four-year follow-up point. A logistic regression analysis found age (40s/70s) (odds ratio 3.38, 95% confidence interval 1.45-7.86), living situation (single/living together) (odds ratio 1.98, 95% confidence interval 1.07-3.68), and ODI scores (every 1%) (odds ratio 1.05, 95% confidence interval 1.01-1.09), to all be significantly associated with high stress.Conclusion　This study suggests that age, living situation, and ODI scores are related to future stress.

Objective　Several studies have suggested that high dietary Na/K ratio and body mass index (BMI) increase the prevalence of hypertension. However, there have been a few reports on the combination of these two factors and their relationship with hypertension. This study aimed to examine the association of the combined estimated 24-h urinary Na/K ratio (24h-u-Na/K) (high or low) and BMI (high or low) with the risk of high blood pressure.Method　We performed a cross-sectional study involving 1,112 participants (340 men and 772 women) of the Kobe Orthopedic and Biomedical Epidemiological study (KOBE study) who had no cardiovascular diseases or current anti-hypertensive medications. Sex-specific analyses were performed. The 24h-u-Na/K ratio was calculated from an estimation formula using collected spot urine. Participants were divided into four groups based on their 24h-u-Na/K ratio (low or high) and BMI (low or high), with the cutoff points being the median and 25 kg/m 2 , respectively.　Participants with systolic blood pressure (SBP) ≥130 mmHg or diastolic blood pressure (DBP) ≥80 mmHg were diagnosed with high blood pressure. Odds ratios (ORs) for high blood pressure according to the combined risks of high 24h-u-Na/K and BMI were examined with a logistic regression analysis.Results　The average SBP/DBP for men and women was 122.7/77.9 and 113.3/69.1 mmHg, respectively, and prevalence of high blood pressure among men and women was 47.4% and 21.3%, respectively. The mean BMI was 22.8 kg/m 2 for men and 20.9 kg/m 2 for women. The median 24h-u-Na/K was 3.2 for men and 3.1 for women. The prevalence of high blood pressure (men, women) was the highest in the group in which both 24h-u-Na/K and BMI were high (60.0%, 62.9%; men: P=0.273; women: P<0.001). In the same group, the multivariate-adjusted ORs for high blood pressure were significantly higher for both men (2.59; 95% confidence interval [CI]: 1.15-5.86) and women (10.78; 95% CI: 4.87-23.88) compared to the reference group with both factors classified as low. Women with low BMI but high 24h-u-Na/K also demonstrated a higher risk for high blood pressure (OR: 1.62; 95% CI: 1.10-2.40).Conclusion　The risk of high blood pressure was the highest when both BMI and 24h-u-Na/K were high. The current specific healthcare guidance in Japan is focused on obese individuals. However, in order to prevent hypertension more effectively, additional focus should be placed on the Na/K diet. Increased intake of vegetables and fruits and reduced intake of salt should be strongly recommended.

A 50-year-old woman was admitted to our hospital with dysesthesia on the right upper portion of her face and a headache. Diffusion-weighted brain magnetic resonance imaging (MRI) revealed high-intensity signals in the dorsolateral portion of the medulla oblongata. She was diagnosed with lateral medullary infarction and was intravenously treated with sodium ozagrel. On the second day of hospitalization, she had nausea and vomiting and showed nystagmus to all directions, suggesting damage to the vestibular nucleus. These manifestations coincided with partial symptoms of lateral medullary syndrome. On the third day of hospitalization, a rash appeared on the region of skin innervated by the first and second branches of the right trigeminal nerve. A reevaluation of the MRI findings indicated the presence of a lesion of the right spinal trigeminal nucleus and tract. She was treated with acyclovir for 14 days, and was discharged without any residual symptoms. Varicella zoster virus-DNA was detected in her cerebrospinal fluid. This disease mimics the presentation of a stroke and is important for differential diagnosis. (Received August 1, 2017; Accepted September 14, 2017; Published February 1, 2018).

Objectives　The Patient Survey provides basic information on disease and injury statistics of patients in Japan, and an estimation of the number of patients by disease and injury can be made using this survey. In this survey, the number of outpatients with repeat visits affects the survey results. The average interval since last visit (AILV) and a correction factor are used to estimate the number of repeat outpatients. Patients with AILV > 30 days are not included in the survey. However, in the last years, AILV exceeded 30 days in many cases, suggesting that the current 30-day threshold is no longer suitable. Thus, this study investigated the AILV in the current patient population and the effect of the increase in AILV on the number of repeat outpatients.Methods　Patients Survey data of 1996-2011 were used to estimate the effect of changing the AILV threshold on the number of repeat outpatients.Results　AILV increased for patients with most diseases and injuries. Using the current 30-day threshold, the overall outpatient coverage rate decreased from 91% in 1996 to 78% in 2011. A higher AILV threshold was necessary to maintain the overall outpatient coverage rate. For example, a threshold of 90 days increased the coverage rate in 2011 to 96%. However, raising the threshold markedly increased the number of repeat outpatients. For example, the overall number of repeat outpatients in 2011 increased from 43.01 million with the current 30-day threshold to 71.03 million using the 90-day threshold. The peak of the AILV of outpatients was observed on the next day after the first visit and the peak of the AILV of outpatients was observed every other week.Conclusion　AILV increased over time and changing the AILV threshold markedly increased the number of repeat outpatients and total patients, indicating that there is a need to raise the AILV threshold.

We managed 6 cases of severe liver atrophy and failure associated with paclitaxel and bevacizumab combination therapy (PB therapy)for HER2-negative metastatic breast cancer. In this case-controlstudy, we examined the records of these 6 patients to investigate past treatment, medication history, and degree of atrophy, and compared their data with that of 67 patients without liver atrophy. The degree of the liver atrophy used SYNAPSE VINCENT®of the image analysis software. The results showed that patients with liver atrophy had a longer pretreatment period than those without liver atrophy(33.5 months vs 15.5 months), and they also experienced a longer median time to treatment failure with PB therapy than other patients(11 months vs 6 months). The ratio of individuals presenting with diffuse liver metastasis among patients with liver metastasis was 80% with liver atrophy, compared to 8% without liver atrophy. The degree of liver atrophy was an average of 67%in terms of volume ratio before/after PB therapy(57-82%). The individualwith the greatest extent of liver atrophy died of liver failure, not as a result of breast cancer progression. The direct causal link between bevacizumab and liver atrophy and failure is unclear, but the individuals in this study had a long previous history of treatment, and diffuse liver metastases may develop in patients undergoing long periods of PB therapy, which may also cause liver atrophy; therefore, the possibility of liver failure should be considered in such cases.

The purpose of this study is to propose a method of factor analysis for analyzing contingency tables developed from the data of unlimited multiple-choice questions. This method assumes that the element of each cell of the contingency table has a binominal distribution and a factor analysis model is applied to the logit of the selection probability. Scree plot and WAIC are used to decide the number of factors, and the standardized residual, the standardized difference between the sample, and the proportion ratio, is used to select items. The proposed method was applied to real product impression research data on advertised chips and energy drinks. Since the results of the analysis showed that this method could be used in conjunction with conventional factor analysis model, and extracted factors were fully interpretable, and suggests the usefulness of the proposed method in the study of psychology using unlimited multiple-choice questions.

Transfusion-related acute lung injury (TRALI) is known to be the leading cause of transfusion-related mortality. A nearly fatal case of postoperative TRALI, successfully managed with extracorporeal membrane oxygenation (ECMO), is reported. The patient was a 70-year-old woman for whom laparoscopic nephrectomy was planned. She received several units of packed red blood cells and fresh-frozen plasma (FFP) intraoperatively due to massive bleeding. At the end of the operation, her PaO2/FIO2 ratio was 504, and she was extubated. Shortly after extubation, she developed severe hypoxemia. A chest X-ray showed bilateral infiltrates without cardiac enlargement. After entering the ICU, her respiratory condition deteriorated rapidly despite treatment with noninvasive positive pressure ventilation followed by re-intubation 8 hours after the operation. Even with very high positive pressure ventilation above 35 mmHg, her oxygenation decreased to PaO2 39.9 mmHg (FIO2 1.0). As a lifesaving measure, venovenous ECMO was started 15 hours after the operation. The pulmonary infiltration improved significantly over the next 5 days. Anti-HLA antibodies were detected in the FFP donor serum, that was transfused at the time of extubation. Now that TRALI is thought to be reversible, ECMO might be useful for even what was previously fatal hypoxemia.

In this study, we assessed 11 patients who were definitively diagnosed with tuberous sclerosis complex (TSC) based on the accepted clinical diagnostic criteria (Roach, 1998). We compared the clinical and radiological findings of six adult-onset TSC cases (group A) and five child-onset TSC cases (group B). The prevalence rates of generalized tonic-clonic convulsions at onset, mental retardation, facial angiofibroma, and epilepsy were lower in group A than in B group. The number of cortical tubers and subependymal nodules on brain magnetic resonance (MR) and computed tomography (CT) images were also lower in group A. The number of cerebral white matter radial migration lines was similar in both groups. Cortical tubers were most frequently observed in the frontal lobe in both groups. The number of cortical tubers and subependymal nodules did not correlate with the presence of epilepsy or mental retardation. Extra-brain lesions in lung, kidney, and bone were recognized in both groups, and no specific lesions were noted in group A.

We present a case of holmium : YAG laser resection of superficial bladder tumor (HoLRBT). A 73-year-old male was referred to our hospital with elevated prostatic specific antigen. Due to difficulty of urination, holmium : YAG laser enucleation of the prostate was performed under the diagnosis of benign prostatic hyperplasia. During the surgery, superficial bladder tumor was incidentally identified, and HoLRBT was performed. After the operation, histopathological examination revealed urothelial carcinoma, G2 ＞ G1, pTa. The patient has been subsequently followed up for 9 months, and there areno evidence of recurrence. Changing the holmium : YAG laser energy setting can potentially be effective and safe to approach a superficial bladder tumor.

A 42-year-old man working at a printing company was referred to our hospital for examination and treatment of icterus. We diagnosed resectable hilar cholangiocarcinoma and provided neoadjuvant chemoradiotherapy, extended right hepatectomy, and extrahepatic bile duct resection. A detailed history revealed that he had used 1,2-dichloropropane as part of his work as an offset colour proof-printer, and he has subsequently been recognized as having occupational cholangiocarcinoma. He has survived without recurrence for more than 2 and half years since the liver resection. In the present report, we describe our valuable experience of neoadjuvant chemoradiotherapy for occupational cholangiocarcinoma.

A 66-year-old man was admitted to our hospital because of unconsciousness. He was diagnosed with pneumococcal meningitis and treated with a combination of antibiotics (meropenem hydrate), dexamethasone, and intravenous immunoglobulin. Although he gradually regained consciousness, he started showing signs of hearing disturbance. Measurement of auditory brainstem response revealed severe sensorineural hearing loss. The patient then underwent three-dimensional fluid-attenuated inversion recovery magnetic resonance imaging, which revealed increased signals in the cochlea and the vestibuum, and their enhancement after gadolinium administration. This enhancement was still observed on images of the inner ear acquired on the 52nd hospital day. These findings suggested that the change of content in the lymph and the damage to the blood-labyrinth barrier was caused and aggravated by an immune response. Recent studies have shown that an MyD88-dependent immune response contributes to hearing loss in an experimental mouse model of pneumococcal meningitis. The patient was administered steroid pulse and hyperbaric oxygen therapies for improving the hearing deficit, but these therapies were discontinued because of the aggravation of hepatitis B and diabetes mellitus, which he had developed previously.

SLE is a systemic autoimmune disease characterized by overactivation of autoreactive memory B cells. However, little is known about the mechanism of qualitative abnormality of B cells. The subset classification of T cells by expression pattern of master transcription factors and chemokine receptors has been established. The biology of T cells is useful information to assess qualitative abnormality of B cells. Therefore, we focused on the expression of chemokine receptors such as CXCR5 and CXCR3 on B cells in order to define the B cell subset classification in patients with SLE. Our results revealed that pathological B cells, which lose CXCR5 and express CXCR3, might be involved in autoantibody production through the interaction with Tfh cells, and in acquisition of effector function of memory B cells during the pathological process in SLE. In addition, the results revealed that those effector B cells still remained after improvement of disease activity by immunosuppressive therapy, indicating that the quantitative abnormality, which is not improved by current therapy, may underlie in this disease.

Bacteria isolated from surgical infections during the period from April 2011 to March 2012 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 785 strains including 31 strains of Candida spp. were isolated from 204 (78.8%) of 259 patients with surgical infections. Five hundred and twenty three strains were isolated from primary infections, and 231 strains were isolated from surgical site infection. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from surgical site infection aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp. and Staphylococcus spp., in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from surgical site infection. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Pseudomonas aeruginosa and Enterobacter cloacae, in this order, and from surgical site infection, E. coli was most predominantly isolated, followed by P. aeruginosa, K. pneumoniae, and E. cloacae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Collinsella aerofaciens, Lactobacillus acidophilus and Finegoldia magna, and from surgical site infection, E. lenta was most predominantly isolated, followed by P micra and L. acidophilus, in this order. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroidesfragilis was the highest from primary infections, followed by Bilophila wadsworthia, Bacteroides thetaiotaomicron, Bacteroides uniformis and Bacteroides vulgatus, and from surgical site infection, B. fragilis was most predominantly isolated, followed by Bacteroides caccae, B. thetaiotaomicron, Bacteroides ovatus and B. wadsworthia, in this order. In this series, vancomycin-resistant MRSA (methicillin-resistant Staphylococcus aureus), vancomycin-resistant Enterococcus spp. and multidrug-resistant P. aeruginosa were not observed. We should carefully follow up B. wadsworthia which was resistant to various antimicrobial agents, and also Bacteroides spp. which was resistant to many β-lactams.

Changes in sexual function and ejaculatory function in patients who had undergone holmium laser enucleation of the prostate (HoLEP) were investigated using questionnaires. In this study, 77 patients on whom HoLEP was performed at our department from July 2010 to December 2010 were included. Of the 77 patients, the number of patients who could achieve an erection increased from 36 (46.8%) preoperatively to 52 (67.5%) postoperatively after HoLEP. Although postoperative ejaculatory dysfunction was found in 38 (73%) of 52 patients, 47 (90%) experienced orgasms, regardless of ejaculation, which is a high rate. With respect to ejaculatory satisfaction, patients who experienced an ejaculation had significantly higher satisfaction levels than those who did not. These results suggest that changes in postoperative ejaculatory function might affect satisfaction levels of ejaculation.

The incidence of cholangiocarcinoma among the past or present workers in the department of offset color proof-printing at a printing company in Osaka was extremely high. The workers were relatively young and were exposed to several chemicals including organic solvents such as dichloromethane and 1,2-dichloropropane. Although the exact cause of cholangiocarcinoma in the patients remain unknown, it is likely that the development of cholangiocarcinoma was triggered during exposure to these chemicals. Some chemicals can act as environmental factors that lead to the development of cholangiocarcinoma. Therefore, we believe that cholangiocarcinoma is a new type of occupational cancer.

A 39-year-old man was suffered from bacterial meningitis spread from sphenoid sinusitis. During the first several days of the hospitalization, his clinical and laboratory findings were improved by the antibiotics. But he developed impaired consciousness and paraparesis on the sixth hospital day. A CT scan of the brain revealed pneumocephalus with compression of frontal lobes and the widening of the interhemispheric space between the tips of the frontal lobes, which was known as "Mount Fuji sign". Tension pneumocephalus was diagnosed on the basis of the clinical symptoms and the characteristic CT findings. As the bacterial meningitis itself was improving, the surgical treatment was not performed, but the antibiotics therapy continued. He gradually recovered and discharged without any other complications. The mechanism of tension pneumocephalus could not be disclosed. However, it was speculated that tension pneumocephalus was formed due to combined conditions of following factors; the fistula formation between sphenoid sinus and subdural space, the reduced CSF pressure on lumbar puncture, and a ball-valve mechanism though the fistula. We would emphasize that "Mount Fuji sign"on CT or MRI was the important finding to diagnose tension pneumocephalus.

A 54-year-old woman presented with complex partial seizure with impaired consciousness. Brain MRI revealed a high intensity lesion on T2-weighted and FLAIR images in the left temporal lobe, indicating limbic encephalitis. CT and MRI of the pelvis showed right ovarian teratoma. The cerebrospinal fluid (CSF) were positive for antibodies against the GluRε2, GluRδ2, and antibodies against NR1 + NR2B heteromers. On the basis of these data, anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis associated with ovarian teratoma was suspected, and the right ovariectomy was performed. Six months after onset, brain biopsy from the right temporal lobe led to a diagnosed of glioblastoma. This is the first glioblastoma case with ovarian teratoma having autoantibodies against GluR and NR1 + NR2B heteromers in CSF. We suggest that patients with NMDAR antibodies should be carefully diagnosed with anti-NMDAR encephalitis.

A 55-year-old man underwent rectal amputation for rectal cancer in August 2005. A tiny thin-walled cavity lesion in his left S1+2 was found on computed tomography (CT) of the chest in November 2008. The cavity lesion in the left S1+2 gradually increased in size over 3 months and positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) showed FDG accumulation at the lesion. Videoassisted thoracoscopic (VATS) wedge resection was performed to make a definite diagnosis in March 2009. The pathological findings revealed a metastatic lung tumor from the rectal cancer. It is necessary to consider the possibility of metastatic lung tumors in a case with the cavity lesions especially in patients with a history of colon cancer.

Background: It has been confirmed by several clinical trials that the fentanyl patch causes less adverse events than sustained-release oral morphine, and after rotation. However, there has been no evidence comparing the fentanyl patch with controlled-release oral oxycodone in terms of adverse events., Purpose: We prospectively investigated the reduced effects of adverse events caused by sustained-release oral morphine and controlled-release oxycodone after rotating to the fentanyl patch in patients with metastatic breast cancer., Method: Metastatic breast cancer patients requiring sustained-release oral morphine or controlled-release oral oxycodone(n=9, 2 taking oral morphine, 7 taking oral oxycodone, mean age, 57. 5 years)were recruited. Those experiencing adverse events from oral morphine or oral oxycodone were administered a fentanyl patch., Results: The pain score was reduced significantly at the 4th week. The fentanyl patch was associated with significantly less nausea, vomiting, constipation, sleepiness and dizziness over the study period., Conclusion: This study suggested that the fentanyl patch can reduce adverse events caused by sustained-release oral morphine as well as controlled-release oral oxycodone.

Dendritic cells (DCs) is the cell that act as source of the immune response by exquisitely presenting antigens to acquired immunity such as the T cells. Janus kinase (JAK) is a tyrosine kinase that is activated immediately after the cytokine binds to its unique receptor expressed on the cell surface. Among the JAKs, expression of JAK3 is limited on haematopoietic cells and is indispensable for lymphocyte development and proliferation. We have demonstrated that JAK3-deficient DCs normally develop, uptake antigens, produce inflammatory cytokines and function as an antigen-presenting cell, although they over-produce IL-10. Among the transcription factors that are known to be activated by JAK3, we explored the phenotype of Stat6-deficient DCs which is a transcription factor specifically activated by JAK3. Interestingly, development, function and inflammatory cytokine production was normal with over-production of IL-10 which was in line with the JAK3-deficient DCs. IL-4 is well known to activate JAK3-Stat6 in the cytoplasm and has been reported to be produced in the synovial fluid of rheumatoid arthritis patients. Hence the suppression of IL-10 production by IL-4 can be considered as one of the inflammatory process of arthritis. Moreover, induction of IL-10 production by DCs can be one mechanism of action of the JAK inhibitor (tofacitinib) which have shown high efficiency on active rheumatoid arthritis in clinical trials.

Treatment of rheumatoid arthritis (RA) has dramatically developed with the use of biologics targeting inflammatory cytokines. However, expense and parenteral use can cause issues in the initiation and continuation of the treatment. Therefore a new orally available anti-rheumatic drug has been long-awaited. Recently, small-molecule compounds targeting Janus kinase (JAK) has shown clinical efficacy similar to biologics in clinical trials for active RA. Among the JAK-inhibitors, new drug application for tofacitinib is concurrently under review in western and asian countries and is highly expected to become a new anti-rheumatic drug in the near future. In order to evaluate the mode of action, we utilized peripheral blood and synovium from RA patients. Proliferation and cytokine production of CD4+ T cell was prominently reduced and subsequently inhibited cartilage destruction by the synovium. Our result is in line with the inhibitory effect of tofacitinib on joint destruction in RA patients those who were treated with tofacitinib. Therefore, further clinical efficacy is expected in the in the long-term treatment with tofacitinib.

Objective: We examined the relationship between morcellation efficiency and enucleated tissue weight in holmium laser enucleation of the prostate (HoLEP) for patients with benign prostatic hyperplasia (BPH) retrospectively., Methods: From January to December 2010, 140 patients with BPH were treated by HoLEP combined with mechanical morcellation with up side down technique by a single surgeon., Results: The mean age was 70.6 years, and the mean enucleated tissue weight was 46.8 g. The mean morcellation time was 9.9 min, and the mean rate of morcellation was 6.7 g/min. No complications were reported relating to morcellation such as bladder injury. Although morcellation time and enucleated tissue weigh were proportionally related (Estimate equation: Y = - 1.186 + 0.813 * X, R^2: 0.814), larger glands with more than 80 g of tissue enucleated did not match this distribution map. Five cases with more than 100 g of enucleated tissue weight required much longer operation time (range 66-90 min) and were disproportioned to tissue weight. Morcellation efficiency tended to decrease when enucleated tissue weight exceeds 80 g and less than average in almost all cases. Morcellation efficiency significantly worsen when enucleated tissue weight exceeds more than 100 g., Conclusions: Morcellation efficency may decrease in larger gland exceeds 80 g.

Bacteria isolated from surgical infections during the period from April 2009 to March 2010 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 671 strains including 16 strains of Candida spp. were isolated from 174 (79.1%) of 220 patients with surgical infections. Four hundred and eleven strains were isolated from primary infections, and 244 strains were isolated from surgical site infection. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from surgical site infection aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from surgical site infection. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Enterobacter cloacae and Pseudomonas aeruginosa, in this order, and from surgical site infection, E. coli was most predominantly isolated, followed by P. aeruginosa and E. cloacae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Streptococcus constellatus and Finegoldia magna, and from surgical site infection, E. lenta was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of Bilophila wadsworthia was the highest from primary infections, followed by Bacteroides fragilis, Bacteroides ovatus and Bacteroides thetaiotaomicron, and from surgical site infection, B. fragilis was most predominantly isolated, followed by B. ovatus, B. wadsworthia and B. thetaiotaomicron, in this order. In this series, we noticed no vancomycin-resistant Gram-positive cocci, nor multidrug-resistant P. aeruginosa. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.

Objectives: The present study was performed to elucidate the effects of individual and social factors on smoking behavior of parents of fourth grade elementary school students in Japan., Methods: A self-administered questionnaire was sent to a total of 4,179 households of fourth grade elementary school students. A total of 3,522 responses including actual numbers of children, smoking behavior of parents, and marital status were available for the analysis., Results: Current smoking rate in mothers was 21.2%. In mothers, "smoking of spouse" "single mother", "under the age of 34", "not taking child-care leave;", "mother's parents not alive", "mothers from Chiba", "nursery use", "not use parenting circles", "unvaccinated measles or inoculation unknown" and "life dissatisfaction" were statistically associated with smoking behavior. The current smoking rate in fathers was 51.4%. Four factors of "smoking of spouse", "under the age of 34", "non-skilled labor, sales work" and "employees of private companies of less than 1,000 employees" were statistically associated with smoking behavior., Conclusion: The present study demonstrated a close link between smoking behavior and individual socioeconomic status in Japanese parents. Especially, smoking of spouse and being a single female parent were important factors for smoking.

Oral anticoagulation (OA) has been considered as a strict contraindication to transurethral resection of the prostate (TURP). In recent years, some studies have shown that holmium laser enucleation of the prostate (HoLEP) has less blood loss compared to TURP. Thus we have performed HoLEP in patients with benign prostatic hyperplasia (BPH) under continuous OA from September 2009, and herein we report our first nine cases. Patients received HoLEP by a single surgeon at our institution. HoLEP was performed successfully in all patients. The mean times to complete enucleation and morcellation were 48.2 and 5.1 minutes, respectively. The mean tissue weight of enucleation was 37 grams. The mean hemoglobin and sodium loss after HoLEP were 1.7 g/dl and 1.3 mEq/L, respectively, and the catheterization time was 1.6 days. Blood transfusion, clot retention or transurethral resection syndrome were not observed in any cases. HoLEP has excellent hemostatic properties, and is a safe and effective procedure for patients with symptomatic BPH under the condition of continuous OA.

An 79-year-old man admitted our hospital for abdominal mass. Computed tomography showed a tumor measuring about 10 cm in diameter without any metastasis lesion and any sings of local infiltration. Gastroduodenal endoscopy revealed the presence of a submucosal tumor in the third portion of the duodenum, and biopsy revealed tumor cells stained positive for c-kit. These findings were consistent with a GIST and we performed a partial resection of the duodenum sparing the pancreas. Gastrointestinal stromal tumors (GIST) were mainly located in the stomach and the small intestine. Duodenal localization is rare. Surgical approach for GISTs should basically be a partial resection. However, for GISTs located in the duodenum, the partial resection was sometimes difficult and pancreaticoduodenectomy (PD) may be needed, depending on the tumor size and the location of the tumor close to the papilla Vater. Since GIST grew expansively, rarely involving lymph nodes, PD may be an excessive procedure to treat the disease. For this reason pancreas-sparing partial duodenectomy has been introduced for the treatment of duodenal GIST.

We report a long-term survival case treated by chemotherapy with new anticancer drugs such as S-1, CPT-11 and docetaxel after bilateral overiectomy for bilateral ovarian metastases of progressive gastric cancer. A 68-year-old female, who had undergone total gastrectomy with D2 lymphadenectomy for scirrhous gastric cancer of Stage IIIA, was admitted because of ovarian metastasis. Laparoscopic bilateral ovariectomy was performed for ovarian metastases of the gastric cancer (Krukenberg tumor) 6 months after gastrectomy. Seven months after gastrectomy, 11-course of S-1 treatment (80 mg/m2) for bilateral ovarian metastases of the gastric cancer was administered. CT scan revealed mediastinal lymphadenopathy 2 years and 5 months after gastrectomy. Then, the drug was changed to docetaxel (60 mg/m2). After 9-course of docetaxel treatment, the mediastinal lymphadenopathy disappeared. For a treatment of grade 3 neuropathy, a 12-course CPT-11 was started after gastrectomy 3 years and 6 months ago. CT scan and PET-CT showed no new metastasis in 4 years and 10 months after gastrectomy.

A 74-year-old man was admitted to our hospital in order to treat a mediastinal mass and 2 ground-glass attenuations in the right upper lobe detected by chest X-ray and computed tomography (CT). Partial resection of right lung and thymectomy were performed. The mediastinal mass and 2 ground-glass attenuations in the right upper lobe proved to be thymoma and bronchioloalveolar carcinomas, respectively by pathology.

Laninamivir is a novel neuraminidase inhibitor of influenza viruses and it has been reported that its prodrug, CS-8958 shows a long-lasting characteristics. Using viruses isolated in Nagasaki of pandemic (H1N1) 2009 influenza virus which cause pandemic in 2009, it was shown that laninamivir has a strong inhibitory activities against their neuraminidases and virus replication in cultured cells, and strong binding stability to the virus NA. Furthermore, a single intranasal administration of CS-8958 showed a superior reduction of virus load in lungs in mouse infection model. These suggest that CS-8958 will work as a long-acting neuraminidase inhibitor to an infection with pandemic (H1N1) 2009 influenza viruses as well.

Holmium laser enucleation of the prostate (HoLEP) is a safe and effective treatment for patients with symptomatic benign prostatic hyperplasia (BPH), but is a difficult operation. To shorten the learning curve, we evaluated the surgical outcome of successive bilateral lobe enucleations with HoLEP. Performed by an inexperienced endourologist and an expert. Between March and July on 2009, we evaluated 20 cases of HoLEP performed by a beginner who underwent successive bilateral lobe enucleations and 20 cases of HoLEP performed by an expert. Enucleation time was shortened when successive bilateral lobe enucleations were performed by the beginner using HoLEP (115 vs 92 minutes, p<0.05). The enucleation time was significantly shorter in the expert group than in the beginner group. However, there were no significant differences in morcellation time, enucleated tissue weight, hemoglobin decrease level, sodium decrease level, catheterization time or significant incontinence time between the two groups. The postoperative evaluations was excellent in both groups. We conclude that HoLEP is a safe and effective operation. However, close supervision by an expert is required. In addition, learning from the easier part of enucleation to elaborate skill sets required to perform HoLEP is prerequisite for success.

A 72-year-old woman was reffered to our hospital for further examination of a tumor shadow in the left upper lung field which was detected in a mass screening chest X-ray. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a chest wall tumor located in the left 4th intercostal space. The lesion was suspected to be neurogenic tumor and CT-guided needle biopsy was performed. The tumor was consisted of spindle-shaped cells, but immunohistochemistry demonstrated no evidence of neurogenic tumor. As a possibility of malignant tumor could not denied, we performed tumor resection under video-assisted surgery. The lesion was not originated from nerves, but adhered to the intercostal muscle. Histologically, the tumor was consisted of spidle-shaped cells without atypia which sparsely proliferate in the myxoid stroma adjacent to intercostal muscle. In immunohistochemistry, tumor cells were positive for vimentin, and negative for desmin, S-100 protein, smooth muscle actin, CD34 and factor VIII. It was diagnosed as intramuscular myxoma. This histology in the intercostal muscle is extremely rare.

Bacteria isolated from infections in abdominal surgery during the period from April 2008 to March 2009 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 712 strains including 18 strains of Candida spp. were isolated from 173 (80.5%) of 215 patients with surgical infections. Three hundred and sixty-six strains were isolated from primary infections, and 346 strains were isolated from postoperative infections. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from postoperative infections aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from postoperative infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa, in this order, and from postoperative infections, P aeruginosa was most predominantly isolated, followed by E. coli, Enterobacter cloacae, and K. pneumoniae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Streptococcus constellatus and Gemella morbillorum, and from postoperative infections, E. lenta was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis was the highest from primary infections, followed by Bacteroides thetaiotaomicron, Bacteroides ovatus and Bilophila wadsworthia, and from postoperative infections, B. fragilis was most predominantly isolated, followed by B. thetaiotaomicron, B. wadsworthia and B. ovatus, in this order. In this series, we noticed no vancomycin-resistant methicillin-resistant S. aureus, and Enterococcus spp., nor multidrug-resistant P aeruginosa. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.

A 42-year-old woman was admitted to our hospital because of an abnormal shadow on chest X-ray. Chest computed tomography scan revealed a tumor 4.0 cm in diameter in the right segment S8. We resected the right lower lobe because of the possibility of lung cancer. Historical finding of the resected specimen revealed epithelial-myoepithelial carcinoma of the lung. The patient has remained disease-free for a year and 3 months postoperatively.

A 59-year-old man was admitted to our hospital for abdominal mass and found to have a gastric cancer with peritoneal dissemination. Three courses of neoadjuvant chemotherapy combined with S-1 and CDDP were performed. This chemotherapy showed a substantial reduction of the size of primary tumor and peritoneal dissemination by CT examination. Surgical resection consisted of distal gasterectomy and D2 lymph node dissection was performed, and an ip catheter was placed through the douglas pouch, and the catheter was attached to the subcutaneous portal delivery system for ip chemotherapy. Operative cytology of ascites proved positive and remnant neoplasm cells were identified in the peritoneum. The pathological stage was determined as T3 N2 H0 P1 CY1 M0, pStage IV. Following surgery, we selected the ip administration of paclitaxel at a dose of 100 mg per body. Finally, the peritoneal dissemination was re-grown. However, we continued the ip chemotherapy for twenty-five times on ambulant basis. Most gastric cancer patients with peritoneal dissemination die within a few months, and there is no standard treatment for peritoneal dissemination from gastric cancer. In conclusion, a condition of no progression has been achieved and maintained for more than three years by intraperitoneal administration of paclitaxel for patient with peritoneal dissemination due to advanced gastric cancer.

Bacteria isolated from infections in abdominal surgery during the period from April 2007 to March 2008 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 707 strains including 24 strains of Candida spp. were isolated from 181 (79.0%) of 229 patients with surgical infections. Three hundred and ninety-five strains were isolated from primary infections, and 288 strains were isolated from postoperative infections. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from postoperative infections aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from postoperative infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Pseudomonas aeruginosa and Enterobacter cloacae, in this order, and from postoperative infections, P. aeruginosa was most predominantly isolated, followed by E. cloacae, E. coli and K. pneumoniae. Among anaerobic Gram-positive bacteria, the isolation rate of Parvimonas micra was the highest from primary infections, followed by Streptococcus constellatus and Gemella morbillorum, and from postoperative infections, Anaerococcus prevotii was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of both Bacteroides fragilis and Bilophila wadsworthia were the highest from primary infections, followed by Bacteroides thetaiotaomicron and Campylobacter gracilis, and from postoperative infections, B. thetaiotaomicron was most predominately isolated, followed by B. fragilis, Bacteroides caccae and B. wadsworthia in this order. In this series, we noticed no vancomycin-resistant Gram-positive cocci, nor multidrug-resistant P aeruginosa. There were nine strains of coagulase-negative Staphylococci which show higher MIC against teicoplanin more than 4 gg/mL, but all of them had good susceptibilities against various anti-MRSA antibiotics. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.