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In May 2022, Hyogo Medical University Hospital introduced protocol-based pharmacotherapy management(PBPM), which is jointly planned by doctors and pharmacists, for certain cancer drug therapies. Colorectal cancer patients who underwent outpatient cancer chemotherapy in the Department of Lower Gastrointestinal Surgery from October to December 2021(before the introduction of PBPM)and from May to August 2022(after the introduction of PBPM)were retrospectively studied. The proportion of clinical examinations performed, number of prescription questions, and time taken by pharmacists to solve the prescription questions before and after the introduction of PBPM were compared. Additionally, the number of modifications made in the medical record by pharmacists on behalf of doctors in response to the prescription questions was assessed. The proportion of clinical examinations performed(clinical examinations actually performed/clinical examinations that should have been performed)improved from 93.2%(260/279)before to 98.8%(405/410)after the introduction of PBPM(p<0.001). The number of prescription questions decreased from an average of 64.7(±11.9)per month before to an average of 29.5(±3.4)per month after the introduction of PBPM. The average number of modifications made in the medical record by pharmacists on behalf of the doctors in response to the prescription questions was 25.8(±5.4)per month after the introduction of PBPM. There was no significant difference before and after the introduction of PBPM in regard to the median(interquartile range)time taken by pharmacists to solve the prescription questions (before PBPM: 1.88 minutes per case[1.70-2.28 minutes]; after PBPM: 1.71 minutes per case[1.61-2.06 minutes][p= 0.75]). The increased proportion of clinical examinations performed after the implementation of PBPM may have improved the safety of cancer drug management, and the decreased number of prescription questions is speculated to have led to a reduction in physician workload.

Subsequent to a medical examination, a 61-year-old male was referred to our hospital with jaundice. He was diagnosed with intrahepatic cholangiocarcinoma involving the hepatic hilum and was referred to our department to undergo a left trisectionectomy of the liver, extrahepatic bile duct resection, and regional lymphadenectomy. He was discharged on postoperative day 39 without liver failure. Two months postoperatively, positron-emission tomography/computed tomography(PET/ CT)indicated recurrences in the bone, and paraaortic lymph node. Gemcitabine and cisplatin combination first-line therapy was administered. Disease progression occurred after 4 courses of therapy. Gene panel testing was performed and the patient was switched to pembrolizumab owing to high microsatellite instability. After 2 courses of pembrolizumab, notable shrinkage of the paraaortic lymph node recurrence was confirmed on computed tomography as well as a partial response. PET-CT revealed disappearance of abnormal accumulation in all lesions at 20 months postoperatively. This has been sustained for 24 months following surgery without remarkable immune-related side-effects.

Yersinia enterocolitica is a causative agent of food poisoning and has been isolated from pork and stream water, causing Yersinia enterocolitica in humans. The bacterium is divided into multiple serotypes and biotypes, among which serotypes O3 and O8 and biotypes 1B, 3, and 4 are frequently isolated in Japan. Biotype 3 can be classified as [VP+, Suc+], [VP-, Suc+], [VP-, Suc-] based on the biochemical properties. Among them, [O3, 3, VP-, Suc-] has been reported to be identified as Yersinia kristensenii in a simple identification kit. An increasing number of facilities in the field of microbiological testing are currently using mass spectrometers to identify species of microorganisms. However, there are many facilities where mass spectrometers have not yet been installed and microbial identification and susceptibility testing devices are used to identify bacterial species. No reports have described how the [O3, 3, VP-, Suc-] type, which is identified as Y. kristensenii in the simple identification kit, is identified by the microbial identification and susceptibility testing devices. In this study, 15 strains of Y. enterocolitica , which were previously isolated, serotyped, and biotyped from fecal culture tests at our hospital, were analyzed to see how these strains were identified in RAISUS S4, Microscan WalkAway, VITEK2 Blue, and BD Phoenix. [O3, 3, VP-, Suc-] was identified as Y. kristensenii in RAISUS S4, Microscan WalkAway, and VITEK2 Blue and as Y. enterocolitica in BD Phoenix. [O3, 3, VP-, Suc+], [O3, 4] and [O8, 1B] were identified as Y. enterocolitica . Therefore, when a sample was identified as Y. kristensenii by RAISUS S4, Microscan WalkAway, or VITEK2 Blue, the possibility that it was actually [O3, 3, VP-, Suc-] could not be ruled out. The possibility of Y. enterocolitica should be informed to attending physicians.

A 79-year-old man underwent a radical resection for cecal cancer. The pathological diagnosis was pT4a, N1a, M0, pStage Ⅲb(Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma, 9th edition). He was treated with oral UFT/LV as adjuvant chemotherapy for 6 months. At 7 months, after the end of treatment, he lost all the nail plates on his fingers and toes. A dermatologist examined him and diagnosed these as side effects of the anticancer drugs. Due to this issue, he was unable to perform routine, fine work using his fingertips. Approximately 1 year and 5 months after the completion of treatment, his nail plates regenerated to the extent that about half of his nail beds were covered. At 2 years after the completion of treatment, the nail plates began to cover the entire nail beds. Although there have been very few reports of onychomadesis as a delayed adverse event of anticancer drugs, oncologists must be aware of this possibility, as onychomadesis may impact patients' quality of life significantly.

In cancer chemotherapy, identifying factors that may affect overall survival is clinically beneficial. In this study, we examined the factors associated with overall survival in patients treated with gemcitabine plus paclitaxel(albumin suspension) (GN)for pancreatic cancer. We included 91 pancreatic cancer patients who underwent GN therapy as the first-line treatment from January 2015-November 2021. In addition to survival from the start of therapy, the factors surveyed were patient background(gender, age, BMI, etc), dose at the start of treatment, baseline laboratory values, presence or absence of neutrophil count reduction, and modified Glasgow Prognostic Score(mGPS). Multivariate analysis showed that a neutrophil count reduction of Grade 3 or higher(p=0.004)and mGPS≤1(p=0.004)significantly increased overall survival. Consequently, 54.9% of patients(50/91)showed a neutrophil count reduction of Grade 3 or higher, and 35.2% of patients (32/91)showed expression of the first course. The study suggests that neutrophil count reduction of Grade 3 or higher and mGPS≤1 are indicators of prolonged overall survival. In particular, neutrophil count reduction had a high incidence in the first course; therefore, appropriate management is required from early stages of treatment. In addition, nutritional support care should be considered prior to starting treatment.

A 77-year-old woman visited our hospital after noticing bleeding during defecation. Lower gastrointestinal endoscopy revealed an early rectal tumor with extension into the anal canal, thus transanal excision was performed. However, histopathological examination revealed a positive surgical margin, therefore, additional transanal excision was performed with endoscopic submucosal dissection, and the residual cancer tissue was completely resected. At one year after surgery, no recurrence has been observed.

In December 2021, abemaciclib was approved as an adjuvant treatment for hormone receptor-positive, HER2-negative, high-risk early breast cancer in Japan. The Oncotype DX Breast Cancer Recurrence Score program(Oncotype DX)is a test that can be used to limit overtreatment in hormone receptor-positive, HER2-negative, low-risk early breast cancer. Although the target groups of both these are different and usually without many overlapping indications, we encountered a case in which this therapy and test were used in a short time period. Our experience suggests that even if the result of Oncotype DX indicates that hormone therapy alone is sufficient, it does not imply that abemaciclib is unnecessary, although this has not been directly studied in the monarchE trial. While a wider choice of treatment options is desirable for patients, more clinical data and trials are needed to further validate the utility of abemaciclib without chemotherapy.

Recurrent mutations in genes encoding key splicing factors, SF3B1, SRSF2, U2AF1, and ZRSR2 have been found in a variety of cancers, particularly in hematologic malignancies, including myelodysplastic syndromes, chronic myelomonocytic leukemia, acute myeloid leukemia, and chronic lymphocytic leukemia. Global mis-splicing of mRNAs targeted by aberrant splicing factors partly contributes to leukemogenesis through decrease protein expression of tumor suppressors and epigenetic modifiers, caused by mRNAs degradation of aberrantly spliced. Some of the mis-spliced mRNAs influence intracellular oncogenic pathways and cellular processes through a dysregulated expression of associated proteins, whereas others influence the function of co-mutated genes such as aberrant transcriptional regulators. Spliceosomal disruption is common in many cancers, making spliceosome an appealing therapeutic target. The findings that spliceosomal mutant cells rely on wild-type splicing machinery for survival and that splicing factor mutations occur in a mutually exclusive manner strongly suggest that inhibiting wild-type splicing machinery causes synthetic lethality in cancer cells with these mutations. We discuss the characteristics and oncogenic mechanisms of splicing factor mutations, as well as the development of novel treatment strategies targeting aberrant splicing factors in hematologic malignancies.

A man in his 60s had end-stage alcoholic cirrhosis. About six months before his death, hepatic peribiliary cysts (HPBC) rapidly increased, and he developed jaundice and liver failure. The pathological autopsy performed after his death revealed that his intrahepatic bile duct was pressured due to multiple cysts caused by HPBC, which resulted in liver failure. Some cases of HPBC have been associated with alcoholic cirrhosis;however, no other cases of increased HPBC in a short period of time have been reported. Although identifying the cause of increased HPBC in a short time is difficult in this case, it may be have been caused by continuous alcohol drinking after the onset of HPBC. Most patients with HPBC have liver cirrhosis and obstructive jaundice that may promote liver failure as in this case. Therefore, patients with HPBC should not only be instructed for abstinence but also promptly consider effective treatments in the event of obstructive jaundice to prevent liver dysfunction.

A 61-year-old woman was found to have calcifications in the CD region of the left breast. She had previously undergone total hysterectomy and bilateral oophorectomy for endometriosis at the age of 37 years. Since age 59 years, she had been attending an otorhinolaryngology clinic because of vertigo. Blood tests showed no abnormal findings. Left breast cancer (cT1N0M0, stage Ⅰ)was diagnosed, and left mastectomy and sentinel lymph node biopsy were performed. She developed postoperative nausea, and at 37 hours postoperatively, she was unable to communicate and exhibited suspected delirium. At 43 hours postoperatively a tonic-clonic seizure occurred. Hyponatremia, with serum sodium of 114 mEq/L, was present. Sodium supplementation was provided, and the patient became capable of communication 8 hours after seizure onset(Na 121 mEq/L). A hyponatremic tonic-clonic seizure is extremely rare after breast cancer surgery, and the abnormal behavior of the present patient 31 hours after surgery was also highly unusual. With such an unusual presentation, the possibility that something specific is happening must be considered. This case gave us the opportunity to review patient management after breast cancer surgery, emergency response and preparations, and nursing education from the medical safety perspective.

Palbociclib(PAL), which is a small molecule with inhibitory activity against cyclin-dependent kinase 4/6, is used in endocrine combined therapy for the treatment of estrogen receptor(ER)-positive and HER2-negative inoperable and recurrent breast cancer. We retrospectively investigated the factors associated with prolonged treatment in inoperable and recurrent breast cancer in a multicenter study. The median time-to-treatment failure(TTF)after PAL was 5.6 months(0.2-22.5). A total of 28 patients in the fulvestrant(FUL)group and 21 patients in the aromatase inhibitor(AI)group received concomitant endocrine therapy. The median TTF was 2.6 vs 6.7 months(p=0.015)for white blood cell(WBC), 3.7 vs 6.6 months (p=0.021)for neutrophils(Neu), and 2.8 vs 7.5 months(p=0.007)for lymphocytes(Lym). The treatment period tended to be prolonged in the group with higher WBC, Neu, and Lym levels than that of the standard values. The median treatment duration of the FUL group was 7.5 months vs 4.2 months(p=0.162); however, the difference was not statistically significant. The WBC, Neu, and Lym levels upon PAL introduction may be factors affecting the prolonged treatment. Further analysis of the data and further investigation of the prolongation-related factors of PAL treatment period are necessary.

A new nivolumab and pembrolizumab monotherapy regimen with double the conventional dose and longer dosing intervals( the new regimen)has been approved. Here, we report the incidence of immune-related adverse events(irAEs)in the early phase of switching from the conventional regimen to the new regimen at Ogaki Municipal Hospital. Thirty-seven patients switched to the new regimen between October 2020 and February 2021: 7(18.9%)switched to nivolumab and 5 (14.3%)to pembrolizumab. Two of the 7 patients treated with nivolumab developed irAEs. One patient developed Grade 3 colitis on day 51 following the switch to the new regimen, and the treatment was discontinued. The other patient developed Grade 3 adrenal insufficiency on day 72 and was hospitalized. No irAEs were observed with pembrolizumab treatment. These results suggest that high-severity grade irAEs may occur early after switching to the new regimen.

Prospective studies have demonstrated the efficacy of pembrolizumab in patients with previously treated unresectable or metastatic microsatellite instability-high(MSI-H)cancers. Pembrolizumab has been covered by the Japanese health insurance system since December 2018. The frequency of MSI-H in patients is as low as approximately 2%. In addition, some patients with MSI-H cancers are diagnosed with Lynch syndrome. In the present study, we retrospectively investigated patients who received MSI testing at Kitasato University Hospital from April 2019 to June 2020. We also investigated the therapeutic effect of pembrolizumab for MSI-H cancers and patients who received genetic counseling for Lynch syndrome. Results identified that 5 out of 263 patients who underwent MSI testing(1.9%)had MSI-H. The therapeutic outcomes of pembrolizumab in those patients were as follows: 1(20%)complete response, 3(60%)partial response, and 1(20%) progressive disease. The positive-outcome rate of MSI-H treatment in our institution was comparable to that in the previous reports. The high response rate of pembrolizumab was confirmed in the present study. Four out of 5 patients received genetic counseling at the genetic clinic, and 1 patient underwent genetic testing for Lynch syndrome. No deleterious variant of Lynch syndrome was detected in the genetic testing.

The addition of anti-angiogenic agents to cytotoxic agents to improve outcomes has become the standard treatment for metastatic colorectal carcinoma. In this study, we evaluated the safety of bevacizumab plus FOLFIRI with that of ramucirumab plus FOLFIRI in second- and later-line treatment in Japanese patients with metastatic colorectal carcinoma. Patients who received ramucirumab or bevacizumab as a second- and later-line treatment between January 2016 and March 2020 were included. Treatment regimens, body surface area, dosage, number of treatment courses, and adverse events( AEs) were evaluated. There were 66 and 17 patients in the bevacizumab plus FOLFIRI and ramucirumab plus FOLFIRI groups, respectively. All patients developed AEs. AEs of grade 3/4 were documented in 84.8% and 100% of the patients in the bevacizumab plus FOLFIRI and ramucirumab plus FOLFIRI groups, respectively. Progressive disease was the most common reason for treatment discontinuation in both groups. Twelve (18.2%) and 5 (29.4%) patients in the bevacizumab plus FOLFIRI and ramucirumab plus FOLFIRI groups, respectively, discontinued treatment due to AEs. The most common AEs leading to discontinuation were malaise and decreased performance status. The findings of our study indicated that both bevacizumab plus FOLFIRI and ramucirumab plus FOLFIRI groups have a high incidence of AEs, and that medical professionals need to be aware of the frequent development of malaise and decreased performance status.

The patient was an 81-year-old man who visited a clinic for fever and lower abdominal pain. He was subsequently diagnosed with prostatitis based on computed tomography (CT) findings that showed swelling of the prostate. Despite treatment with antibacterial therapy, his symptoms did not improve significantly. Since the patient also had myelodysplastic syndrome, he was transferred to our hospital and subsequently diagnosed with prostate abscess based on findings on magnetic resonance imaging (MRI). The abscess had spread widely from the dorsal side of the trigone of the bladder to anterior wall of the rectum. Transperineal drainage was performed to preserve the urethral mucosa of the prostatic urethra. Considering the shape of the abscess cavity, one pigtail catheter was placed in the prostate and another was placed transperineally on the dorsal side of the trigone of the bladder. Cystostomy was performed at the same time. Culture of the abscess revealed the presence of Staphylococcus aureus. As there was little exudate from the abscess 9 days after drainage, the pigtail catheter on the dorsal side of the trigone of the bladder was removed following an injection of minocycline into the abscess. CT showed shrinkage of the abscess 4 days later, and the remaining intraprostatic pigtail catheter was removed after an injection of minocycline. The cystostomy pigtail catheter was subsequently removed since the patient was able to urinate smoothly after clamping. MRI confirmed the disappearance of the abscess cavity 2 months later.

A 75-year-old woman presented to our department with a liver tumor. She had undergone left total mastectomy and axillary lymph node dissection for left breast cancer at the age of 67 years. Subsequently, she had taken an aromatase inhibitor. A follow-up abdominal echo revealed a 50 mm tumor in the liver. Based on examinations, she was diagnosed with an intrahepatic cholangiocarcinoma. She underwent laparoscopic lateral segment hepatectomy. Pathological diagnosis showed liver metastasis of the breast cancer. After surgery, she received hormonal therapy. After 5 months, multiple brain metastases appeared. She died 15 months after the liver operation.

A 52-year-old female had cholecystoduodenostomy for biliary atresia of type I cyst at 120 days of age. The patient's surgery recovery was uneventful;however, the patient had recurring cholangitis at the age of 27. The patient had high hepatobiliary enzymes in the outpatient clinic and was diagnosed with cholangitis. In general, the Kasai method is the mainstream for biliary atresia, since it has a much-reduced incidence of both early and late postoperative problems. However, this patient had biliary atresia of type I cyst and had undergone cholecystoduodenostomy. We suspected that the obstructive cholangitis was caused by the relatively wide anastomosis opening into the duodenal bulb, where the stomach contents pass through the most, and the poor clearance owing to the convoluted cystic duct;therefore, we chose to place a stent endoscopically. However, to our surprise, Class V was detected in the bile cytology performed as a precaution. Although no tumor was seen on imaging such as contrast-enhanced CT, EUS, and PET/CT, mapping biopsy results showed the presence of cancer at the bifurcation of the cystic duct. The patient had cholangiocarcinoma confined to the extrahepatic bile ducts only;thus, extrahepatic bile duct resection was conducted. The patient was discovered to have biliary intraepithelial neoplasia-3, and the tumor was entirely respectable. The patient had a good postoperative course, with normalization of liver function and no recurrence of cholangitis. In this case, cholangiocarcinoma was detected at an early stage by cytological examination performed as a precaution during endoscopic therapy for recurrent cholangitis. In addition to the fact that the long-term pathogenesis of biliary atresia is still unknown, it is important to note the presence of malignancy, which has the greatest effect on the patient prognosis, considering that the course of the disease varies depending on the operation carried out. Because cholecystoduodenostomy for biliary atresia is a rare approach, and there has been no previous report of related cholangiocarcinoma, we report this case for the benefit of gastroenterologists who may encounter similar cases in the future.

Abdominal ultrasonography during a regular medical examination showed that a 70-year-old man had an approximately 10 cm cystic tumor in the lower abdomen. Abdominal computed tomography showed that the appendix had swollen to a size of 130 mm×44 mm. As no other tests suggested malignancy, the patient's condition was diagnosed as a low-grade appendiceal mucinous tumor and he underwent laparoscopic ileocecal resection and lymph node D2 dissection. Laparoscopic surgery was completed without damaging the tumor. There has been no recurrence after the operation for 2 years now.

(Introduction) Percutaneous cystostomy is a standard urological procedure; however, very few reports have focused on the many cases of this procedure performed in Japan. We analyzed the background of the procedure and its approach as well as the incidence of its complications at our institution. (Material and methods) We examined 95 patients who underwent percutaneous cystostomy between April 2010 and March 2019. A comparative analysis was conducted for each type of procedure performed. Furthermore, cases that experienced accidental catheter extraction before the first catheter replacement were analyzed, and the three patient groups were compared based on the type of procedure performed and cases that needed another operation. (Result) The indications for cystostomy were urethral stricture (56.3%), neuropathic bladder (13.5%), and prostatic hyperplasia (11.5%). The complications included hemorrhage, peritoneal injury, urinary tract infection, and catheter damage caused by a puncture needle. The overall complication rate was 10.5%. Based on type of the procedure performed, the incidence of hemorrhage was found to be as high as 25% in patients who underwent the procedure using a cannula puncture needle. Accidental catheter extraction before the first catheter replacement occurred most frequently in patients treated with Seldinger technique (17.0%). The rate of complications including accidental catheter extraction ranged from 25.0% to 25.4% among the three groups. (Conclusion) We prefer the Seldinger technique for the first placement of the cystostomy catheter because of its low rate of hemorrhage, but a cannula puncture needle may also be used by using exploratory puncture if vascular damage and accidental catheter extraction are avoided.

A 67-year-old man was diagnosed with a submucosal primary gastric T-cell lymphoma (PGTL) via upper gastroenteroscopy following an annual health check-up. He received six cycles of CHOP and achieved a complete remission. However, the patient relapsed 4 months post therapy. A second remission, which was maintained for years, was achieved after surgical gastrectomy followed by adjuvant chemotherapies. Prior reports have shown that surgery combined with chemotherapies was curative for patients with newly-diagnosed PGTL. In this report, surgery combined with chemotherapies was successfully applied for early-relapsed PGTL.

Granulomatous mastitis is a chronic inflammatory disease of unknown causes that forms a breast mass and may be difficult to distinguish from breast cancer on imaging studies. The patient was a woman in her 50's. Needle biopsy was performed for a mass in the upper outer quadrant of the right breast and revealed granulomatous mastitis. Breast magnetic resonance imaging showed that the tumor was malignant. Taking into account that there is a difference between histologic findings and imaging findings and that surgery after steroid therapy for granulomatous mastitis is more likely to cause complications, we decided to perform lumpectomy. The definitive pathological diagnosis was a triple negative, pT1cN0cM0 medullary carcinoma. Postoperative adjuvant chemotherapy was performed. The absence of axillary lymph-node metastasis was confirmed by right axillary sentinel lymph-node biopsy. Radiotherapy was performed on the preserved breast region. Even if granulomatous mastitis is diagnosed, biopsy should be repeated while paying attention to biopsy methods if there is a difference between pathological findings and image findings.

The patient was a 79-year-old woman with a left breast mass. Magnetic resonance imaging showed a cystic mass with a diameter of 10×8 cm and an ulcer in the upper outer quadrant and the nipple-areola region of the left breast. Intracystic carcinoma was thus suspected. A mass with a diameter of 1 cm was found in the upper outer quadrant of the right breast. Needle biopsy revealed that a cystic mass in the left breast was diagnosed as a malignant phyllodes tumor. A mass in the right breast was diagnosed as Luminal A breast cancer. The clinical tumor stage was T1N0M0. Computed tomography showed no enlarged bilateral axillary lymph nodes. In the left breast, mastectomy was performed with extensive skin excision above the tumor. In the right breast, partial mastectomy was performed with sentinel lymph node biopsy. On postoperative pathological examination, the diagnosis of left breast tumor was triple-negative spindle-cell carcinoma. The pathological tumor stage was diagnosed as T4bNxM0. Taking into consideration treatment according to breast cancer stage and age, we selected 4 courses of weekly-paclitaxel, endocrine therapy, irradiation to the left chest wall, and irradiation to the residual right breast. The preoperative diagnosis was malignant phyllodes tumor. The postoperative diagnosis was switched from malignant phyllodes tumor to spindle-cell carcinoma. It was therefore difficult to determine the presence or absence of additional resection and postoperative treatment regimens. Even though the preoperative diagnosis was a malignant phyllodes tumor, surgical procedures such as sentinel lymph-node biopsy should be considered, taking into account the possibility of breast cancer.

We investigated factors related to the recurrence and prognosis of patients with triple-negative breast cancer (TNBC)after neoadjuvant chemotherapy(NAC). Of the 545 patients who underwent surgery after NAC between January 2013 and December 2016, 131 patients had TNBC. An analysis of each TNBC case indicated that the presence or absence of clinical lymph node metastasis(cN)before treatment might be a predictive factor of prognosis. There were 57(43.5%)pathological complete response(pCR)(ypT0 or ypTis/N0)cases after NAC. Overall survival(OS)and disease free survival(DFS) were significantly better in pCR cases than in non-pCR cases. However, recurrence was observed in 8 of 57(14%)pCR cases and 29 of 74(39%)non-pCR cases. The factors defining DFS from the univariate analysis of the non-pCR group were cN, ypT, ypN, and vascular invasion. The multivariate analysis of these factors suggested that residual cN and vascular invasion might be independent factors predicting DFS. Residual vascular invasion was found to predict OS, and was considered to be a poor prognostic factor.

A woman in her 30s presented to our hospital with the chief complaint of a right breast mass after the birth of her first child. She was diagnosed as having right invasive ductal carcinoma of Luminal-B type and T3N3cM0, stage Ⅲc. While undergoing neoadjuvant chemotherapy, she received genetic counseling and underwent genetic testing and was determined to have deleterious BRCA1 and BRCA2 mutations. After completing chemotherapy, she underwent a right total mastectomy and axillary lymph node dissection. Two years postoperatively, she requested to undergo a contralateral risk-reducing mastectomy( CRRM)of her left breast. Therefore, CT and breast MRI were performed to confirm the absence of contralateral lesions and distant metastases, and subsequently, CRRM was performed. Postoperative pathology results showed non-invasive ductal carcinoma lesions at 5 sites. In the case of hereditary breast and ovarian cancer syndrome such as in this study, lesions may be discovered at an early stage by performing risk-reducing mastectomy.

The PCR-based open reading frame typing (POT) is an important method for analyzing outbreak information. Many institutions use POT as a molecular epidemiological method for analyzing horizontal transmission in methicillin-resistant Staphylococcus aureus (MRSA). However, typing and analyzing MRSA only based on POT, with high detection frequency, has some limitations. In this study, we analyzed 62 strains of MRSA, isolated at Ehime University Hospital between January 2018 to December 2018 based on six POT types, toxin type, and antimicrobial susceptibility. Types of POT and strains used were as follows: 106-183-37 (28 strains), 106-137-80 (7 strains), 106-77-113 (7 strains), 106-9-80 (7 strains), 70-18-81 (7 strains), 106-247-33 (6 strains). Based on antimicrobial susceptibility patterns, 5 types of MRSA were detected, including types susceptible to gentamicin (GM), clarithromycin (CAM), and levofloxacin (LVFX). Strains belonging to the same POT type, showed differential antimicrobial susceptibility patterns and had different toxin productivity. These findings suggest that the combination of POT method with antimicrobial susceptibility patterns and toxin type may be a useful technique for MRSA typing.

Venetoclax, a selective BCL-2 inhibitor, is prescribed clinically for acute myeloid leukemia (AML) treatment. However, it is unclear if known chromosomal or genetic abnormalities associated with AML also influence BCL-2 expression. Few studies have examined BCL-2 expression in AML-related precursor neoplasms such as primary myeloid sarcoma (MS) and blastic plasmacytoid dendritic cell neoplasm (BPDCN). In this study, we examined BCL-2 expression using immunohistochemistry in 7 patients with AML, who also carried genetic and chromosomal abnormalities typical to AML including t (8;21), t (15;17), FLT3-ITD mutation, and complex karyotype, along with 1 patient with primary MS and 3 patients with BPDCN. As a result, expression of BCL-2 was observed in all patients with AML and 1 patient with primary MS. In the patients with BPDCN, BCL-2 was highly expressed in all regions with evidence of tumor cell infiltration, such as skin, bone marrow, and lymph node. These results could be used as evidence in the support of administering venetoclax to adverse-risk patients with AML, MS, or BPDCN.

Surgical resection is the standard treatment for the management of localized penile cancer and a neo-urethral meatus is generally created on the penile stump or perineum. Neo-urethral meatus is often stenosed and requires repeated transurethral manipulations such as dilation and urethrotomy. These procedures are generally futile and are associated with poor quality of life. Here, we report a case of penile cancer that developed a neo-meatal stenosis after total penectomy, which was subsequently salvaged by perineal urethrostomy using Blandy technique. A 72-year-old male who was diagnosed with localized penile cancer, underwent total penectomy and creation of neo-meatus on the perineum. Neo-meatus stenosis had developed in the patient and he received repeated urethral dilations without any success. Finally, when the patient was unable to void, he was referred to us for the amelioration of meatal stenosis through the placement of a suprapubic catheter. Because the condition of the residual bulbar urethra was adequate and its length was enough, we planned to create a non-transecting perineal urethrostomy by Blandy technique. An inverted U-shaped perineal incision was made, and a skin flap was created. The scarred neo-meatus and spongiofibrosis at the distal bulbar urethra were completely excised. The residual bulbar urethra was exposed, and a longitudinal ventral incision of 4 cm was made. The edge of the bare urethral mucosa and tunica albuginea of the corpus spongiosum were sutured by 4-0 PDS for hemostasis. The apex of the U-shaped skin flap was brought to the proximal margin of the urethrotomy and a tension-free anastomosis was created between the skin flap and the urethral plate. Thereafter, the skin of the perineum was sutured to the open longitudinal urethrotomy. The patient started to void on the 5 th day post-surgery. The subject could void without the help of any intervention and did not require any instrument, sixteen weeks after the surgery.

A 53-year-old woman presented at our hospital because of a mass in the left breast. A mass measuring 2 cm in diameter was palpated in the upper outer region(C region)of the left breast. Mammography showed a mass with calcification. Mammary ultrasonography showed a mass measuring 18×16×14mm and enlarged lymph nodes in the left axillary region. Core needle biopsy revealed Luminal B invasive ductal carcinoma(scirrhous type). The estrogen receptor(ER)positivity was 95%, progesterone receptor(PgR)positivity was 60%, human epidermal growth factor receptor type 2(HER2)score was 2+, fluorescence in situ hybridization(FISH)showed no amplification, and Ki-67 index was 60%. Clinical T1N1M0, StageⅡA cancer was thus diagnosed. As preoperative chemotherapy, the patient received 4 courses of treatment containing epirubicin (100mg/m2), 5-fluorouracil(500mg/m2), and cyclophosphamide(500mg/m2; FEC100), and 4 courses of treatment containing docetaxel and cyclophosphamide(TC). Clinical complete response(cCR)was confirmed on imaging studies. The patient was explained about the need for surgery, but she refused to undergo surgery. The patient is being followed up while receiving endocrine therapy, and there has been no recurrence or metastasis as of 2 years. We described our encounter with a patient with breast cancer who refused surgery after preoperative chemotherapy and has had no recurrence or metastasis during follow-up.

The patient was a 50-year-old woman. She had been diagnosed with bilateral breast tumors at another hospital 5 years previously and was followed up every 2 months. Ultrasonography showed hypoechoic masses in her breasts. The largest tumor in the right breast was 15mm in diameter and located in region A, while that in the left breast was 8mm in diameter and located in region B. Magnetic resonance imaging(MRI)showed multiple bilateral breast tumors. The largest tumor was 12mm in diameter and was suggestive of breast cancer. Core needle biopsies(CNB)of the largest tumors in both breasts were performed. Intraductal papilloma(IDP)and low-grade intraductal papillary carcinoma were diagnosed in the right and left breasts, respectively, on immunohistochemical staining. We performed left nipple-sparing mastectomy with sentinel lymph node biopsy and right tumor excision for diagnoses of carcinoma of the left breast(cTisN0M0)and IDP of the right breast. The histopathological diagnosis of the left breast tumor was pT1aN0M0, triple negative breast cancer with extensive intraductal components, and that of the right breast tumor was IDP with atypical ductal hyperplasia. Chemotherapy was administered postoperatively. Several studies have reported that peripheral IDP often coexists with or follows the development of carcinoma. Therefore, we should also closely follow-upthe patient's right breast.

Combination chemotherapy with pertuzumab, trastuzumab, and docetaxel is recommended as the first-line treatment for patients with HER2-positive unresectable or metastatic breast cancer. We report 2 cases of unresectable breast cancer for which pertuzumab, trastuzumab, and docetaxel therapy was effective. Case 1: A woman in her 40s was diagnosed with TxN3aM0, Stage ⅢC, HER2-positive, hormone receptor-positive advanced breast cancer. After administration of 6 courses of pertuzumab, trastuzumab, and docetaxel therapy, she underwent surgery(Bt+Ax[Ⅱ]). Histopathological examination revealed that chemotherapy effect was Grade 3. Case 2: A woman in her 60s was diagnosed with de novo Stage Ⅳ, HER2- positive, hormone receptor-negative breast cancer. She was administered 8 courses of pertuzumab, trastuzumab, and docetaxel therapy as the third-line treatment, because she initially refused treatment. Thereafter, she underwent surgery(Bt+Ax [Ⅰ]). In both cases, histopathological examination revealed complete response after chemotherapy. Thus, combination therapy of pertuzumab and trastuzumab may improve the prognosis in patients with HER2-positive breast cancer.

A 55-year-old man underwent distal gastrectomy and D2 lymph node dissection for type 2 gastric cancer of the antrum. One year later, CEA elevation was discovered, and contrast-enhanced abdominal computed tomography(CT)revealed a 40 mm mass in the liver(S8), which was judged to be a metastatic recurrence of the gastric cancer.S -1 plus CDDP was administered in 5 courses, followed by regular treatment with S-1 alone.Two years after the recurrence was diagnosed, the patient's CEA level was found to be normal, and CT revealed almost total scarring.After 2 more years, there was still no sign of recurrence, so, with the patient's consent, we discontinued the chemotherapy.Eight years after the gastrectomy, a 10mm nodular shadow was observed in the left lower lung lobe, and resection was performed.Despite the earlier diagnosis of gastric adenocarcinoma, this mass was considered a primary lung adenocarcinoma, and the patient died of small-cell lung cancer 11 years and 8 months after the gastrectomy.It is notable that the liver metastasis in this case responded to the S-1 plus CDDP and S-1 therapies, and this response is considered in light of the literature.

We report our experience with a patient with breast cancer who showed recurrence in the nipple skin 5 years and 10 months after a breast-preserving surgery. The patient was a woman, and was 65-years old at the time of initial surgery. Breast-preserving surgery and axillary lymph-node dissection were performed for left breast cancer. Invasive ductal carcinoma of the breast(pT3N0M0)was triple-negative, and the patient postoperatively received adjuvant chemotherapy. Left breast pain developed 5 years and 6 months after surgery. Computed tomography showed no evidence of recurrence, and the symptoms resolved after treatment with non-steroidal anti-inflammatory drugs(NSAIDs). After 3 months, however, the left nipple had enlarged to about 1.5 cm, and the surrounding skin was red and painful. Treatment with NSAIDs was thus resumed. After 1 week, redness of the nipple skin and pain were improved. However, the nipple had enlarged to twice its normal size. Nipple skin biopsy was subsequently performed, and revealed adenocarcinoma invading the skin. Left axillary lymph-node metastasis was suspected, but there was no evidence of metastasis to other sites or recurrence. Conservative total mastectomy with axillary lymph-node dissection was thus performed. The histopathological diagnosis was the recurrence of invasive ductal carcinoma, arising mainly in the reticular layer of the dermis. Chemotherapy was administered postoperatively. There has been no evidence of recurrence as of 1 year after surgery.

The patient was a 51-year-old woman with a mass in the left breast.At the first presentation, she had abdominal distension and liver dysfunction.Mammography showed a category 5 mass in the left breast and a category 4, unstructured region in the right breast.Pathological examination revealed bilateral, invasive ductal carcinomas.Stage II B disease(clinical T2N1M0)was diagnosed in the left breast, and Stage I disease(clinical T1N0M0)was diagnosed in the right breast.Computed tomography revealed a massive uterine myoma compressing the inferior vena cava.Liver dysfunction was suspected to be caused by these factors.Preoperative chemotherapy was scheduled to treat breast cancer.A gynecologist stated that "uterine myoma is unlikely to cause liver dysfunction" and refused to perform a hysterectomy.However, we diligently negotiated with him to avoid chemotherapy-induced venous thrombosis and pulmonary infarction; eventually, a hysterectomy(3.6 kg)was performed. After surgery, liver function was normal.Subsequently, breast cancer could be safely and adequately treated.In patients who have benign disease, as well as malignant tumors, treatment of the malignant tumors is generally given the highest priority.However, there are cases when the treatment of benign disease has priority over the treatment of malignant tumors.It is therefore important to intensively discuss such cases with physicians from other departments.

To examine the efficacy and safety of tadalafil in the treatment of lower urinary tract symptoms suggestive of benign prostatic hyperplasia with chronic pelvic pain syndrome, we treated 23 Japanese men with tadalafil 5 mg once daily for 4 weeks. The mean age of the participantswas58.7 yearsand the prostate volume was25. 2 ml. Significant improvementsin total International Prostatic Symptom Score, International Prostatic Symptom Score Quality of Life Index, total National Institutes of Health Chronic Prostatitis Symptom Index score, pain subscore, urinary symptom subscore, and quality of life impact subscore, were observed for tadalafil versus before treatment. These findings confirm that tadalafil is a valuable new treatment option for patients with benign prostatic hyperplasia complicated by chronic pelvic pain syndrome.

Collaboration with multiple healthcare professionals is important to provide safer and higher quality care. Interprofessional education (IPE) promotes the practice of team-based care. The establishment of Tsurumai-Meijo IPE, including interprofessional education and practice (IPEP) and video-teaching materials, was conducted in collaboration with school of medicine/nursing in Nagoya University and Fujita Health University, because Meijo University does not have its own clinical settings and faculties except for pharmacy. In the established Tsurumai-Meijo IPE, pharmacy, medicine, and nursing students interviewed simulated patients (SP) together or separately and practiced team-based care through Tsurumai-Meijo IPEP. Students could learn in advance and on their own about each professional's knowledge related to patient care by using video-teaching materials from the Meijo IPE homepage. Using a questionnaire survey at the end of program, this study was examined whether Tsurumai-Meijo IPEP, and video-teaching materials were useful for understanding importance of team-based care. More than 83% of students indicated that Tsurumai-Meijo IPE is useful on future clinical practice. This suggests that the program and materials are beneficial to the medical student education. In the optional survey of some clinical pharmacists, who had participated in Tsurumai-Meijo IPE before graduation, they utilized it in their work and it facilitated their work related to team-based care. Tsurumai-Meijo IPE collaborating with SP is likely to contribute to provide high quality and safe team-based care by taking advantage of specialized professional ability of healthcare professionals.

Tazobactam/piperacillin (TAZ/PIPC) is widely used in the treatment of infectious disease. In this study, three hundred and sixty-three patients who were treated with the recommended dose of TAZ/PIPC were investigated for the proportion of time above the minimum inhibitory concentration (%TAM) and the frequency of renal and liver dysfunction. Of the whole patient population, 5.23%, exhibited increased creatinine levels, 9.37% and 8.82% exhibited increased aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, respectively. The patients who exhibited high serum creatinine (SCr) levels before administration, exhibited significant increases of AST (p=0.0121). The patients who exhibited low albumin levels before administration, exhibited significant decreases in renal function (p=0.0041). In the case of a breakpoint (BP) of 64 μg/mL, the arrival probabilities of %TAM of 30% and 50% were 99.4% and 76.9%, respectively. We suggested that the dose of TAZ/PIPC should be adjusted according to the interview form finding and a %TAM>50% (maximal bactericidal action).

The purpose of treatment for patients with metastatic breast cancer is to maintain the patient's quality of life(QOL)with continued treatment for as long as possible.Eribulin was approved in April 2011 for the treatment of metastatic breast cancer, further increasing the selection of therapies available for the management of this disease.The current study presents a retrospective review of 31 patients who received eribulin in our hospital, and analyzes the factors related to the continuation and safety of its use.The median treatment continuation was 114 days(range, 8-281 days), and the treatment involved an average of 5 courses(range, 1-13 courses).There were no significant differences in the continuation of eribulin with regard to the number of previous chemotherapy regimens and modifications undergone by the patients.Neutropenia accounted for 80.6% of adverse eventsBGrade 3; however, the recovery was rapid.The rates of peripheral neuropathy and liver function failures were 12.9% and 6.5%, respectively. These results suggest that eribulin can be continued to be administered with the aim of maintaining QOL, and the therapy can be adjusted according to the patient's situation and the occurrence of adverse events by reducing the dose and treatment delays.

An 80's woman was diagnosed with eccrine porocarcinoma of the head in 2010.T he tumor was removed surgically but relapsed in the cervical and axillary lymph nodes 2 years later.The patient underwent surgery, and received systemic chemotherapy and radiation.Chest CT after treatment revealed an irregular mass and thickened skin in the left breast.Core needle biopsy specimens were used to diagnose metastasis of eccrine porocarcinoma.A wide excision with a 1 cm margin was performed under local anesthesia.After surgery, supraclavicular lymph node recurrence was detected.The patient received palliative care because there was no effective treatment available.Eccrine porocarcinoma is a rare malignant tumor of the intraepidermal sweat duct.Breast metastasis from malignant disease is also rare.To our knowledge, breast metastasis of eccrine porocarcinoma has not been reported.

The patient was a 68-year-old woman who received neo-adjuvant chemotherapy(4 courses of weekly paclitaxel plus bevacizumab and 4 courses of 5-fluorouracil epirubicin, and cyclophosphamide)for cT1N1M0, Stage II A right-sided triplenegative breast cancer(TNBC). Right breast-conserving surgery with axillary lymph-node dissection was performed. The postoperative pathological diagnosis was a complete response. Six months after surgery, the patient developed lower and right-sided back pain. Detailed examination revealed multiple metastases to the liver, bone, lymph nodes of the mediastinum, and bile duct. The recurrence was treated with biweekly paclitaxel plus bevacizumab. The patient's pain dramatically improved. However, the duration of the response was only 3 months. The patient received eribulin as a second-line treatment, but did not respond and subsequently died. TNBC is considered to have relatively good outcomes if a pathological complete response(pCR)is obtained after preoperative chemotherapy. However, recurrence occurred after only 6months in our patient. In patients with TNBC, physical examinations and simple laboratory tests should be performed every 1 to 2 months after surgery, even if a pathological complete response is obtained. We used paclitaxel plus bevacizumab to treat recurrence of TNBC. Although this treatment did not prolong overall or disease-free survival, the patient temporarily responded, and her quality of life was maintained. Further studies are needed to elucidate the pathogenesis of TNBC and to develop more effective treatments.

Our previous phase II clinical trial showed that therapeutically selected personalized peptide vaccines(PPVs)were effective at boosting anticancer immunity; the immune response after PPV was associated with a clinical outcome as a prognostic factor for metastatic breast cancer(mBC). We conducted an early phase II study to evaluate the safety and efficacy of a new regimen using multiple peptide vaccines(KRM-19)for patients with metastatictriple -negative breast cancer. KRM-19 consisted of 19 mixed peptides chosen from the previously reported 31 PPVs according to their anti-tumor immunologiceffec ts and safety profiles for patients with mBC. All patients had histologically confirmed measurable ER-PgR-HER2- mBC and their human leukocyte antigen(HLA) / -A molecules were A2, A3, A11, A24, A26, A31, or A33. KRM-19(19mg/mL)was administrated subcutaneously every week for a total of 6 doses. Concurrent conventional chemo- and/or endocrine therapy were not permitted during treatment. This was an open-label, early phase II study. The primary endpoint was safety and anti-tumor immunologic effect, while the secondary endpoints were clinical responses and progression-free survival(PFS). The estimated enrollment was 10-15 and 8 patients were enrolled(Clinical trial registry number: UMIN000014616). Measurement of peptide-specific cytotoxic T lymphocyte and IgG responses were conducted before and after vaccination. The correlation between PFS and the increased IgG response and/or CTL levels were investigated.

Objective: The efficacy of ramelteon, a sleep agent thought to induce natural sleep through its actions on the melatonin receptors 1 and 2, was evaluated during electroencephalography (EEG)., Methods: We retrospectively analyzed the data from 862 EEG sessions in the electronic medical records of 523 patients (mean age, 8.9 ± 6.4 years; range, 0-38 years) who underwent EEGs in the Department of Pediatrics of Kawasaki Medical School Hospital. We compared the sleep induction statuses of patients not treated with hypnotics and those treated with the following hypnotics: ramelteon, triclofos sodium, and/or chloral hydrate., Results: The success rates of sleep induction in the different groups were as follows: 440/513 (85.7%) in the hypnotic-free, 60/63 (95.2%) in the ramelteon, 209/217 (96.3%) in the triclofos sodium, 36/37 (97.3%) in the chloral hydrate, and 29/32 (90.6%) in the triclofos sodium plus chloral hydrate group. The incidence of adverse reactions was 0/63 (0%) in the ramelteon, 104/199 (52.2%) in the triclofos sodium, 12/31 (38.7%) in the chloral hydrate, and 20/30 (66.7%) in the triclofos sodium plus chloral hydrate group. The mean sleep latency in the ramelteon group was 22.3 ± 12.8 min (range, 5-60 min)., Conclusions: Ramelteon induced sleep significantly more compared to the control group. The incidence of adverse reactions after treatment with ramelteon was significantly lower than after treatment with any of the other hypnotics. These results suggest that ramelteon is useful as a hypnotic during EEG.

A survey of introductory statistics courses at Japanese medical schools was published as a report in 2014. To obtain a complete understanding of the way in which statistics is taught at the university level in Japan, it is important to extend this survey to related fields, including pharmacy, dentistry, and nursing. The current study investigates the introductory statistics courses offered by faculties of pharmaceutical sciences (six-year programs) at Japanese universities, comparing the features of these courses with those studied in the survey of medical schools. We collected relevant data from the online syllabi of statistics courses published on the websites of 71 universities. The survey items included basic course information (for example, the course names, the targeted student grades, the number of credits, and course classification), textbooks, handouts, the doctoral subject and employment status of each lecturer, and course contents. The period surveyed was July-September 2015. We found that these 71 universities offered a total of 128 statistics courses. There were 67 course names, the most common of which was "biostatistics (iryou toukeigaku)." About half of the courses were designed for first- or second-year students. Students earned fewer than two credits. There were 62 different types of textbooks. The lecturers held doctoral degrees in 18 different subjects, the most common being a doctorate in pharmacy or science. Some course content differed, reflecting the lecturers' academic specialties. The content of introductory statistics courses taught in pharmaceutical science programs also differed slightly from the equivalent content taught in medical schools.

The Department of Nursing of the university revised its curriculum for students admitted in 2012 or later, including the introduction of integrated subjects. With the aim of improving the practical clinical skills of students and integrating knowledge, skills, and techniques, the following integrated subjects: Objective Structured Clinical Examination (OSCE) I held in the first term of the third-year (15 hours as one credit), and OSCE II held in the second term of the fourth year (30 hours as one credit), were adopted, and simulation-based education was introduced. In this report, we summarized our experience of a simulation education system for nursing students in the year 2014 aiming to improve students' skill of wheelchair transfer of a patient with left hemiplegia and patient's living environment. Many positive responses, such as usefulness in future nursing training, were obtained upon the introduction of the simulation education system. Issues to be addressed in the future, including lack of sufficient time to practice and availability of rooms, were also noticed.

The objective of this study is to understand the issues and solutions considered by certified nurses(CN)in palliative care (hereinafter referred to as"palliative care CN)regarding discharge support and regional cooperation for cancer patients, and to discover the roles and responsibilities of palliative care CN. Data obtained from training sessions for 22 palliative care CNs was reconfigured and analyzed. As a result, problems related to discharge support and regional cooperation for cancer patients were classified into 13 categories and 3 core categories. The following roles for palliative care CN were proposed to promote discharge support and regional cooperation for cancer patients: (1) Inter-professional sharing of knowledge about patients and their families to reconcile the intentions of the patient and family members with predictions of progression of the illness; (2) Enable hospital nurses to obtain information about patients after discharge in order to establish a clear image for medical treatment; and(3) Support for ward nurses regarding cooperation to alleviate symptoms and offer medical care to patients who are highly dependent on medical care, and to become a point of contact for cooperation with visiting nurses.

Recently, circulating tumor cells (CTCs) of cancer patients have been analyzed as a biomarker of disease progression and as a new prognostic tool.We conducted a pilot study to determine whether CTCs present before and after chemotherapy or peptide vaccination predicted outcome in patients with metastatic breast cancer (MBC). CTCs were isolated from the peripheral blood of MBC patients and evaluated using the CellSearch®System (Janssen Diagnostics). The expression of the HLA classⅠ molecule in the CTCs was analyzed simultaneously by using a flow cytometric system. A CTC-positive test result was defined as five or more CTCs/7.5 mL blood. Nine patients (median [range] age, 64.2 years [44-80 years]) were included. Four (57.1%) of 7 MBC patients with Luminal A subtype tested positive for CTC.Of 6 MBC patients, 5 (83.3%) had a decreased mean number of CTCs, from 35.8/7.5 to 0.4/7.5 mL, after 3 courses of systemic chemotherapy. Furthermore, CTC-HLA class Ⅰexpression level was decreased in 2 (66.7%) of 3 patients after cytotoxic chemotherapy but increased in 4 (80.0%) of 5 patients after 6 vaccinations with tumor-specific peptide vaccines. The number of CTCs and CTC-HLA class Ⅰ expression level in the patients with MBC changed after the treatment with systemic chemotherapy or peptide-vaccine therapy.

Sorafenib is a tyrosine kinase inhibitor (TKI) of the vascular endothelial growth factor receptor (VEGFR) used for advanced renal cell carcinoma. Treatment with sorafenib prolongs progression-free survival in patients with advanced clear-cell renal cell carcinoma. However, in spite of its therapeutic efficacy, sorafenib causes a wide range of adverse events. Cardiovascular adverse events have been observed when sorafenib was used with targeted agents. Although these adverse events like hypertension, reduced left ventricular ejection fraction, cardiac ischemia or infarction were manageable with standard medical therapies in most cases, some had a poor clinical outcome. We report three cases of acute myocardial infarction associated with sorafenib in patients with metastatic renal cell carcinoma.

Background and Aims: Asthma is a chronic disease characterized by airway inflammation; it is sometimes difficult to diagnose. For clinical diagnosis, forced oscillation technique (FOT) measures airway reactance and resistance. By FOT, we investigated respiratory resistance and ventilation perfusion ratio inequality in adults with mild asthma., Methods: We examined 58 adult patients with mild asthma having no inhaled corticosteroid treatment, and 10 adult patients with post-infectious prolonged cough. Using a MostGraph-01 FOT instrument, we evaluated these patients before and after bronchial hyperresponsiveness to acetylcholine (ACh) or histamine (Hist). We measured the following conditions: change of resistance at 5Hz (R5) and 20Hz (R20), R5-R20, reactance at 5Hz, frequency of resonance (Fres), low-frequency reactance area (ALX), and forced expiratory volume in 1 second (FEV1)., Results: There were significant changes of R5, R20, R5-R20, X5, Fres, ALX after provocations for ACh or Hist in all patients with asthma, but not in patients with post-infectious prolonged cough. We calculated the percent decrease in FEV1 after provocation with ACh or Hist. For Ach, this decrease in FEV1 correlated with changes in R20 and Fres for all patients. For Hist, the percent decrease in FEV1 correlated with changes in R5, R20, Fres, and ALX for all patients. Furthermore, we investigated these correlations in patients with normalized bronchial hyperresponsiveness to ACh or Hist. For Ach, the percent decrease in FEV1 correlated with changes in Fres or R5-R20. For Hist, this decrease in FEV1 correlated with changes in R5, R20, and Fres. ROC analysis was used to evaluate the diagnostic value of the ratio of change of Fres in BHR to Hist. The area under the curve was 0.7808 (95% CI=0.657-0.904). A reasonably high specificity (100.0%) and a high sensitivity (53.8%) with a cut-off point of 1.5 in the ratio before and after of Fres were obtained., Conclusion: The changes in FOT parameters (before and after bronchial airway responses) may detect airway resistance and ventilation perfusion ratio inequality even in adult patients with asthma having normalized bronchial hyperresponsiveness to ACh or Hist. That results may be useful for an early diagnosis of asthma.

Identification method positive blood culture bottles with MALDI Biotyper is the most important test on precisely and rapidly, for detamination the bacterial name in sepsis and bacteremia is very significant for decision a cure. This time, we devised a new method "blend" to identify the mixture hypostasis that were come into being by centrifuging blood culture broths and 70% formic acid with MALDI Biotyper (Bruker). This time, we identified 65 samples rapidly with MALDI biotyper by "on plate" and "blend," and verified their effectivity. As a result of six ways (on plate, blend-3, blend-6, blend-9, blend-12, blend-15), the highest detection rate was Gram negative rods: blend-15 (74.1%), Gram positive cocci: blend-9 (56.3%), total: blend-9 (55.4%). Moreover, we confirmed that the detection rate raised to 85.2% (GNR), 71.0% (GPC) and 77.6% (total), and the usefully was suggested. Our invented method is more excellently than recommended on Gram negative rods, especially Enterobacteriaceae, Staphylococcus aureus, and Enterococcus spp.