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The patient was a 49-year-old man presenting with recurrent melena due to progressive ulcerative colitis. One day, he developed left lower facial weakness and dysarthria, and the next day, he was transferred to our hospital because of muscle weakness in his left upper and lower extremities. On admission, neurological findings revealed left hemiplegia, including left facial palsy, dysarthria, and left hemispatial neglect. Brain MRI with diffusion-weighted image showed a fresh infarction in the right anterior and middle cerebral artery territory. Contrast-enhanced CT showed thrombus in the ascending aorta in addition to occlusion of the right internal carotid artery, suggesting the diagnosis of cerebral infarction with an embolic source in the aortic lesion. The intra-aortic thrombus disappeared after 48th day of antithrombotic therapy. Laboratory findings revealed elevated blood viscosity, proteinase-3-anti-neutrophil cytoplasmic antibody (PR3-ANCA), and β2GP1-IgG antibodies, suggesting that the cause of the aortic thrombus may be due to elevated blood viscosity and autoantibodies, as well as highly active ulcerative colitis.

This is a 2-case report of concomitant left atrial( LA) surgical ablation through the left atrial appendage( LAA) for atrial fibrillation( AF) during aortic valve replacement( AVR). Case 1, a 74-year-old man, and Case 2, an 85-years-old woman, were presented for AVR and AF. Under the cardio-pulmonary bypass, right and left pulmonary vein isolations( PVIs) were performed with radiofrequency( RF) ablation devices. Through the opened LAA, an RF lesion was placed to connect the bilateral PVIs and the LAA, and another RF line was placed toward the mitral annulus. A right atrial( RA) isthmus ablation was also performed through a RA incision. Postoperatively, sinus rhythm and both RA and LA contraction were obtained, and have been maintained for 7.5 and 5 years without classⅠ/Ⅲ antiarrhythmic drugs in Case 1 and 2, respectively. This procedure is considered to be effective and safe, although further study is needed.

We present a case of a 41-year-old female presenting with recurrence of ischemic stroke on subtherapeutic doses of dabigatran. She had a history of embolic stroke of undetermined sources at the age of 40, and underwent implantable cardiac monitor implantation and had started dabigatran. One year after the first ischemic stroke, she presented with sudden dysarthria and left hemiparesis and was admitted to our hospital. An MRI of the head revealed acute cerebral infarction in the right corona radiata, and an MR angiography revealed right M2 occlusion. Cervical 3D-CTA revealed a protruding structure on the posterior wall of the carotid artery bulb, which was diagnosed as carotid web. She underwent carotid endarterectomy, and the specimen was pathologically confirmed to be vascular malformation due to fibromuscular dysplasia.

Urinary dysfunction includes an overactive bladder (OAB), post-void residual (PVR)/retention, or both entities. Brain diseases cause OAB, peripheral neuropathies are associated with significant PVR/retention, and multisystem atrophy/spinal cord diseases result in a combination of OAB and PVR/retention. Selective beta 3 adrenergic receptor agonists or anticholinergic agents are the first-choice treatment for OAB and clean intermittent self-catheterization, alpha-blocker and cholinergic stimulant therapy for significant PVR/retention. These therapies may be useful to maximize patients' quality of life and prevent serious complications, such as urosepsis or kidney dysfunction.

We reviewed the autonomic dysfunction in multiple system atrophy (MSA) with reference to the new MDS criteria. MSA is a major neurodegenerative disorder that presents with autonomic and motor dysfunctions (cerebellar ataxia and/or parkinsonism). Autonomic dysfunction in MSA affects urinary, cardiac, gastrointestinal, otorhinolaryngologic, and respiratory functions. Therefore, autonomic dysfunction in MSA should be recognized, collaborating with each faculty for the treatment and care of the patients. Moreover, it is highly recommended that neurologists request for an ultrasound measurement of the post-void residual urine volume. MSA has no cure; hence, active participation in the treatment and care of autonomic dysfunction in MSA patients is warranted.

Objectives　There is little evidence supporting the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from presymptomatic or asymptomatic SARS-CoV-2-infected individuals in Japan, where the incidence of SARS-CoV-2 infection is lower than that in other developed countries. This study aimed to determine whether SARS-CoV-2 transmission can occur from presymptomatic or asymptomatic SARS-CoV-2-infected individuals.Methods　We surveyed all directors of Japanese public health centers for index cases and secondary patients who possibly contracted SARS-CoV-2 infection from a presymptomatic or asymptomatic SARS-CoV-2-infected individual who came under their care before June 20, 2020. The professional staff at the centers routinely perform contact tracing of infected persons based on the guidelines of the Infection Control Act. Four authors independently reviewed reports of 9 index cases of SARS-CoV-2-infected individuals with 17 secondary patients from 8 prefectures and examined the cases to determine whether transmission from a SARS-CoV-2-infected individual in the presymptomatic or asymptomatic state occurred.Results　We reported 7 index cases with 13 secondary patients. 1) An elderly woman acquired SARS-CoV-2 infection from her sustained asymptomatic granddaughter at home, 2) 4 guests and 1 accompanying child waiting at a hair salon acquired infection from the presymptomatic female hair stylist, 3) 2 inpatients acquired infection from a presymptomatic nurse while providing nursing care in close contact, 4) an elderly couple acquired SARS-CoV-2 infection from their presymptomatic relative who was in the 50s during household care at their home, 5) a man acquired SARS-CoV-2 infection from a presymptomatic adult neighbor in an enclosed space with poor ventilation, 6) a presymptomatic man had transmitted infection to another man at a coffee shop while having a discussion on business, and 7) a man in his 50s acquired SARS-CoV-2 infection from a presymptomatic man during 50 minutes of close contact at their office and in a car. These secondary patients had no other likely routes of infection. The interval between the date of symptom onset in the presymptomatic index case and the secondary patient ranged from 2 to 6 days. The incidence rates at the time these infections occurred in the corresponding prefectures ranged from 0.00 to 6.56 cases/1 million person-days.Conclusion　We report the first case of SARS-CoV-2 transmission from a sustained asymptomatic index case in Japan. All secondary patients came into close contact with presymptomatic index cases in areas with poor ventilation.

This is a 2-case report of successful aortic repair surgery for the retrosternal giant aortic aneurysm. Our surgical strategy is "deep hypothermia and left ventricular( LV) unloading under cardiopulmonary bypass before approaching to the aortic aneurysm" in case of possible catastrophic bleeding. Case 1, a 64-year-old woman, had a retrosternal pseudoaneurysm (80 mm) at the distal anastomosis of a Dacron graft used to replace the ascending aorta 7 years before. An LV vent tube was cannulated via the right upper pulmonary vein through an inferior T-shaped ministernotomy. Case 2, an 86-year-old woman, had a retrosternal chronic aortic dissecting aneurysm (66 mm). An LV vent cannula was inserted via the LV apex through a left minithoracotomy. Arch replacement and ascending aorta replacement were performed in Case 1 and 2, respectively, without cardiac, neurological, or any other complications. This strategy is safe and useful in a case with complex aortic disease.

An 81-year-old man with esophageal cancer had undergone subtotal thoracic esophagectomy and retrosternal reconstruction using a gastric tube. He developed anemia. Gastrointestinal endoscopy was performed, which revealed a tumor in the posterior wall of the lower part of the gastric tube. Biopsy revealed well-differentiated adenocarcinoma. There was no lymph node metastasis and no distal metastasis on CT. We performed partial resection of the stomach tube because of his age and physical condition. We identified the position of the tumor by upper gastrointestinal series CT and gastrointestinal endoscopy. The tumor was located on the posterior wall of the lower part of the gastric tube and the back of the sternum lower border. Marking was performed by gastrointestinal endoscopy before operation. We simulated the operation and decided to perform laparostomy without sternotomy incision. We cut the anterior wall of the gastric tube in front of the tumor using the endoscope. We could then confirm the diagnosis of cancer, and clipped and removed the tumor from the posterior wall. The resected site was sutured with 4-0 absorbable thread. The pathological diagnosis was T1a(M)N0M0, ly0, v0, PM0, DM0, pStage ⅠA.

We report a case of mediastinal lymph node recurrence of esophageal cancer after endoscopic submucosal dissection (ESD). We first administered chemotherapy and then performed esophagectomy. A 78-year-old man underwent ESD for early esophageal cancer at a different hospital in January 2015. H e was diagnosed pathologically with scc, pSM1, pHM1, pVM0, ly0, v0. Additional treatment was not administered because of his age. In June 2017, chest enhanced CT showed swollen mediastinal lymph nodes. This was diagnosed as a recurrence of esophageal cancer, and he presented at our hospital. We first performed chemotherapy for that lesion, because the swollen lymph node was large and may have invaded the surrounding organs. We then performed esophagectomy.

We report a rare case of liver recurrence of gastric cancer 14 years and 3 months after curative gastrectomy. An 81-yearold man underwent total gastrectomy, D2 lymphadenectomy, Roux-en-Y reconstruction, and cholecystectomy for advanced gastric cancer in November 2002. H e was diagnosed pathologically with M, Type 5, 53×42 mm, tub2>tub1, pT4a, ly2, v2, pN1, pPM0, pDM0, M0, pStage ⅢA(JGCA 15th). Postoperative adjuvant therapy was not administered. He was followed up for 5 years after surgery without adjuvant therapy, and he did not exhibit recurrence. In February 2017, he experienced difficulties in swallowing and visited our hospital. Abdominal contrast-enhanced CT showed an 8×5 cm liver tumor in the lateral segment. Part of the tumor protruded to outside of the liver, and the tumor invaded and pushed the jejunum in the Roux limb. We performed liver biopsy and diagnosed him with liver metastasis of recurrent gastric cancer. Late relapse after gastrectomy, especially after 10 years or more, is very rare.

The patient is a 51-year-old man.Upper gastrointestinal endoscopy revealed gigantic type 3 gastric cancer.Enhanced abdominal CT demonstrated a gigantic mass of 15×7 cm in the stomach, and a large number of peritoneal dissemination with moderate amount of ascites.The patient was diagnosed with cT4aN3bM1(peritoneal dissemination), Stage IV gastric cancer(JPN ver8)and was treated by chemotherapy with docetaxel(40mg/m / 2 day 1)plus cisplatin(60mg/m2 day 1)plus S-1(80mg/m2 day 1-14).After 7 courses of chemotherapy, peritoneal dissemination was disappeared.The patient received total gastrectomy and D2 lymphadenectomy as a conversion surgery.The pathological findings revealed a T0N0M0, stage 0; the tumor was determined to be Grade 3 owing to the chemotherapeutic effect.Without postoperative adjuvant therapy, the patient is alive without recurrence at the 5 years follow-up after operation.

A 63-year-old man underwent a laparoscopic partial gastrectomy for GIST on September, 2001. Three years and 2 months after the gastrectomy, an abdominal CT showed multiple recurrences in S5 and S6 in the liver and peritoneum. After 4 months from the start of imatinib treatment(400mg/day), peritoneal tumors disappeared and the patient maintained stable disease by imatinib treatment for 8 years. However, on December, 2012, an abdominal CT scan revealed the regrowth of the tumor in S6 in the liver, and PET-CT showed focal progression of only the S6 lesion. Although the lesion was resectable, the patient did not request surgical intervention. So, we initiated sunitinib treatment(50mg/day), and the residual liver metastasis has been well controlled with favorable response of sunitinib for 4 years without severe side effects.

A 53-year-old man underwentdistal gastrectomy with Roux-en-Y(R-Y)reconstruction for gastric cancer. An R-Y anastomosis was performed usinga 21mm circular stapler. Five years postoperatively, he visited our hospital with anorexia. An abdominal computed tomography scan showed dilatation of the afferent loop. He was diagnosed with afferent loop syndrome due to R-Y anastomotic stenosis that resulted in poor oral intake and malnutrition. A U-shaped bend created by an adhesion caused a bowel obstruction of the Y-anastomotic site for which the patient underwent R-Y loop reconstruction with an aboral pouch usinga 60mm linear stapler. He has been well without postoperative complaints. Here, we report a case of R-Y loop reconstruction with an aboral pouch for afferent loop obstruction complicated by stenosis of the Y-anastomotic site after distal gastrectomy.

A 72-year-old woman had undergone laparoscope-assisted distal gastrectomy with D1 plus lymph node dissection and antecolic Roux-en-Y reconstruction for early gastric cancer. She visited our department outpatient clinic with left upper abdominal pain 1 year and 9 months after the surgery. CT revealed a spiral sign of the superior mesenteric arteriovenous branch. An internal hernia was suspected on hospitalization. Although abdominal symptoms were relieved by conservative treatment, the hernia persisted. Laparoscopic surgery was performed and revealed that almost entire small intestine had been affected due to Petersen's defect. Since no ischemic changes were observed, the defect was repaired laparoscopically with suture closure. There has been no recurrence of internal hernia after the laparoscopic surgery. Internal hernia after distal gastrectomy is relatively rare. However, the risk of internal hernia is high due to the gap between the elevated jejunum and transverse colon mesentery in Roux-en-Y reconstruction and can lead to intestinal necrosis. Since an internal hernia can occur in patients who have undergone gastric resection with Roux-en-Y reconstruction, suture closure of Petersen's defect should be performed to prevent this occurrence.

Recurrent esophageal cancer has a poor prognosis.However, we sometimes encounter cases with long-term survival after radical treatment for recurrent esophageal cancer.We perform radical chemoradiotherapy aggressively when recurrent esophageal cancer is present in a limited area and is sufficiently localized to be treated by radiation therapy.From June 2010 to December 2014, 150 patients underwent curative esophagectomy for esophageal cancer.Forty -one cases relapsed and we treated 13 of them with radical chemoradiotherapy.Complete response(CR), non-CR/non-PD, and progressive disease(PD) were observed in 5, 6, and 2 cases, respectively.The CR rate was 38.4%.The median survival time from recurrence was 500± 39.7 days, and the 1-year and 3-year survival rates were 84.6% and 28.7%, respectively. Four out of 5 CR cases were single site recurrences.The other case was multiple and regrowth of the cancer was identified 253 days after the CR.These results suggest that radical chemoradiotherapy for recurrent esophageal cancer after curative esophagectomy can achieve long time survival, especially in cases with single site lymph node recurrence.

A 74-year-old man admitted with dysphagia was found to have advanced esophageal squamous cell carcinoma, clinical stage IV (T4N2M0). We initiated definitive chemoradiotherapy(dCRT)with combined 5-fluorouracil and cisplatin chemotherapy( FP therapy)and 50.4 Gy irradiation, followed by boost FP therapy, to which the patient showed confirmed complete response(CR). Local recurrence was detected in the scar of the primary lesion at 4 months after the boost FP therapy. Photodynamic therapy(PDT)for this lesion resulted in CR. Thirteen months later, right hilar and right pericardial lymph node metastases were found. The right hilar lymph node metastases were not visible on CT after triweekly docetaxel therapy, but the pericardial lesions remained. The patient underwent salvage lymphadenectomy without further chemotherapy, and at 5 months after surgery, he was alive and recurrence-free.

A 69-year-old woman who underwent laparoscopic assisted distal gastrectomy for early gastric cancer(pathological T1bN1M0)in June 2011was admitted to the hospital because of abdominal pain in May 2015.A n abdominal CT scan showed ileus caused by a transverse colon tumor and ascending colon perforation.We performed emergency right hemicolectomy and diverting ileostomy.The postoperative pathological findings revealed poorly differentiated adenocarcinoma and signetring cell carcinoma similar to the gastric cancer resected 4 years ago.Immunohistochemical findings showed that the colon tumor was positive for CK7, but negative for CK20 and expressed a gastric mucin phenotype.From these findings, the colon tumor was diagnosed as a metastasis from early gastric cancer.Colon metastasis from early gastric cancer is rare and the diagnosis is difficult in some cases.We herein report this case and discuss the clinical and pathologic features of colon metastasis from gastric cancer.

Neoadjuvant chemotherapy(NAC)is thought to be effective to improve the outcomes in patients with adenocarcinoma of the esophago-gastric junction(AEG). We encountered 3 patients who were confirmed as having a pathological complete response following gastrectomy after NAC. The first patient had Siewert type II and clinical Stage III AEG, the second patient had Siewert type I and clinical Stage III AEG, while the third had Siewert type II and clinical Stage II AEG. Two patients received NAC with 2 courses of S-1 plus cisplatin, while the third patient received 2 courses of docetaxel, S-1, and cisplatin. All of the patients were treated with D2 gastrectomy after the NAC, and remain alive at more than 40 months after initial chemotherapy treatment without recurrence. We report the details of these 3 cases and review the literature.

A 63-year-old man with dysphagia was referred to our hospital. He was found to have a type 2 tumor extending from the lower thoracic esophagus to the esophagogastric junction via upper gastrointestinal endoscopy. A biopsy revealed adenocarcinoma with overexpression of the human epidermal growth factor type 2(HER2). The tumor was type I according to Siewert's classification, as the epicenter of the tumor was 27mm to the oral side from the esophago-gastric junction. The clinical diagnosis was T3N1M1, stage IV according to the Japanese Classification of Gastric Carcinoma, and T3N2M0, stage III per the Japanese Classification of Esophageal Cancer. He was treated with neoadjuvant chemotherapy consisting of 6 courses of capecitabine(1,000mg/m / / 2: days 1-14)plus cisplatin(80mg/m2: day 1)and trastuzumab(8mg/kg: day 1 of the first course, 6mg/kg: day 1 after the second course). Computed tomography(CT)and upper gastrointestinal endoscopy showed shrinkage of the primary esophagogastric cancer and lymph node metastases. The patient had a partial response and underwent radical esophagectomy. The pathological findings revealed a T3N2M0, stage III tumor; the tumor was determined to be Grade 1b owing to the chemotherapeutic effect. At a follow-up examination 1 year and 7 months after the start of chemotherapy, the patient is alive without recurrence.

A30 -year-old woman underwent total gastrectomy with D2 lymph node dissection after being diagnosed with clinical T3, N2, M0, Stage III B gastric cancer. The postoperative pathological findings revealed a T3(SE), N2, M0, Stage III B tumor. Headache, dizziness, and vomiting occurred during chemotherapy for peritoneal recurrence, using weekly paclitaxel on days 1, 8, and 15. Head CT showed a solitary tumor with a diameter of 28mm in the cerebellum, as well as cerebellar swelling and hydrocephalus. She underwent an emergency craniotomy and tumor enucleation. Pathological examination revealed a metastatic brain tumor from the gastric cancer. She received 12 courses of CPT-11 plus cisplatin until discontinuation because of an adverse event. The patient is alive 6 years after the diagnosis of the cerebellar metastasis without recurrence.

We report a case of advanced esophageal and gastric cancer that was successfully treated via multimodal therapy. A 65- year-old man with hoarseness was referred to our hospital. He was diagnosed with clinical T4aN2M0, Stage IV esophageal squamous cell carcinoma and clinical T3N1M0, Stage II B gastric adenocarcinoma. He was treated with 3 courses of chemotherapy, administered over 4weeks, with S-1(80mg/m / / 2: day 1-14), cisplatin(60mg/m2: day 1), and docetaxel(40mg/m2: day 1). Computed tomography(CT)revealed shrinkage of the primary esophageal tumor, gastric tumor, and lymph node metastases. Next, we selected definitive radiation chemotherapy(CRT), because lymph node metastases remained around the bilateral recurrent laryngeal nerves. After CRT with a total 60 Gy plus administration of 5-fluorouracil and cisplatin, CT showed that the primary esophageal tumor and lymph node metastases had disappeared. Then, distal gastrectomy was performed for the remaining gastric cancer, as part of the multimodal therapy. After gastrectomy, no systemic chemotherapy was performed. At a follow-up examination 5 years and 6 months after the start of chemotherapy, the patient is alive without recurrence.

Adjuvant chemotherapy aims to eradicate residual micro-metastatic tumor cells existing at distant sites outside the surgical field. The current standard adjuvant chemotherapy is S-1 for 1 year or capecitabine plus oxaliplatin for 6 months after D2 gastrectomy. However, there are some rooms in the overall survival of Stage III. Neoadjuvant chemotherapy(NAC)is a promising approach that combines intensive chemotherapy with high compliance; however, it is under development in Japan. Two JCOG phase II trials suggested that NAC was effective for bulky nodal disease. For scirrhous-type malignancy, a JCOG phase III trial is currently ongoing investigating the efficacy of a NAC regimen of S-1 plus CDDP. Another group is conducting 2 randomized phase II trials to compare different regimens and courses of NAC. So far, 2 courses of S-1 plus CDDP or 3 courses of S-1 plus oxaliplatin can be recommended as candidates for the test arm of future phase III studies of NAC.

An 80-year-old woman was admitted to our hospital with acute onset of flaccid paraplegia and sensory and urinary disturbances that developed soon after acute pain in her lower back and leg. Neurological examination revealed, severe flaccid paraplegia, bladder and rectal disturbances and dissociated sensory loss below the level of L1 spinal cord segment. MR imaging with T2 weighted imaging (T2WI) and diffusion weighted imaging (DWI) on day 2 showed hyper signal intensity in the spinal cord at the vertebral level of L1 while initial apparent diffusion coefficient (ADC) showed decreased signal intensity in the lesion. We diagnosed spinal cord infarction, and anticoagulant and neuroprotective agents were administrated. Serial MRI findings revealed that the DWI signal of the lesion attenuated with time, and pseudo-normalization of the ADC occurred approximately 1 month after onset. These findings were similar to those seen in brain infarction. Our patient demonstrated serial MRI changes of spinal cord infarction showing anterior spinal cord syndrome.

A 34-year-old man with adrenoleukodystrophy (ALD) was scheduled for pump system insertion of intrathecal baclofen therapy under general anesthesia. ALD, a rare genetic disorder, is associated with a total body increase in long chain fatty acids caused by defective degradation, and includes various nervous system abnormalities, muscular weakness, in addition to adrenal insufficiency. He had contracture of the both legs, and muscular weakness of the left hand, and Mallampati class III, but no respiratory disability. In the operating room, we administered hydrocortisone 100 mg for steroid coverage, and low-dose midazolam, and fentanyl. As spontaneous breathing remained, we could easily see epiglottis and arytenoid cartilage by McGRATH. Therefore we selected rapid-induction of anesthesia with thiamylal, and rocuronium 40 mg, under cricoid pressure. We avoided propofol. Anesthsia was maintained with sevoflurane and remifentanil, monitoring BIS and train of four. No more rocuronium was administered, and anesthesia was uneventful. Intrathecal baclofen therapy is given to patients who have severe contracture. When we selected general anesthesia, we should be aware of the possibility of muscular weakness, and cannot intubate cannot ventilate scenario.

Frailty and sarcopenia both contribute to a functional decline among the elderly, and are reportedly reversible with physical exercise. Locomotive syndrome represents the decline in locomotor function as a result of impairments of the locomotor organs. A healthy locomotor organ is essential for locomotor function, as well as daily living and social activities. Hence, elucidating the mechanism underlying locomotive syndrome may help provide physical fitness professionals with insight into the locomotor function in the elderly. Importantly, locomotor organs primarily undergo degenerative changes after middle age. Moreover, overloading may be a risk factor for degenerated cartilages and intervertebral disks, whereas underloading may also predispose bones and muscles to certain risks.

A 67-year-old woman was referred to our hospital for type 1 gastric cancer. We diagnosed the patient with advanced gastric cancer (tub2>por, HER2-positive), and the clinical findings were T4aN1M1 (lung), Stage Ⅳ. The patient had cancer cachexia. As first-line chemotherapy, a regimen consisting of capecitabine (X) (1,600 mg/m2/day, days 1-14), cisplatin (P) (60 mg/m2/day, day 1), and trastuzumab (H) (8 mg/kg/day>6 mg/kg/day, day 1) was administered every 3 weeks and repeated 6 times. After receiving 6 courses, the patient's general condition and cancer cachexia symptoms improved. The size of the primary lesion significantly decreased, and lung metastasis was not visible on a PET scan. Simultaneously, a new 0-Ⅱc tumor was detected in the cardia, and a biopsy revealed a malignant lymphoma. Total gastrectomy and D2 lymph node dissection without splenectomy were performed. The final diagnosis was T4aN0M0. After treatment, the tumor was histologically evaluated as Grade 1b, and the remnant cancer cells were found to be HER2-negative (loss of HER2). The patient has been alive for 5 months and is receiving adjuvant chemotherapy comprising capecitabine and trastuzumab. Following chemotherapy containing trastuzumab, the patient with cachexia who was diagnosed with unresectable HER2-positive advanced gastric cancer showed improvement in the cachexia symptoms and the disappearance of lung metastasis.

Objective: To evaluate the psychological development of patients with congenital central hypoventilation syndrome (CCHS)., Methods: We performed a questionnaire-based survey of 17 patients with CCHS aged over 7 years and assessed their clinical course, respiratory management, and psychological development., Results: CCHS was present at birth in 15 patients, of which eight presented with respiratory failure with a low Apgar score. Twelve patients required mechanical ventilation with intubation, and five received mask ventilation. All patients with intubation underwent tracheostomy between 1 and 12 months of age (median 5.5 months), and most of them had associated conditions such as Hirschsprung disease. Four of 12 patients with intubation were eventually switched to mask ventilation and one to diaphragm pacing and mask ventilation. The patients undergoing mask ventilation had relatively milder disease severity and had fewer complications than did the patients with intubation. The psychological development of patients who received tracheostomy ranged from normal to severe retardation. Retardation was more likely to be severe in patients who received tracheostomy in late infancy. All patients who received mask ventilation experienced borderline to moderate psychological retardation. This effect could be attributed to poor compliance with mask fitting., Conclusion: Our findings suggest that the psychological development of CCHS patients was influenced by hypoxia; tracheostomy and strict respiratory management since the neonatal period were needed for neurological protection.

Deafferentation, like as in limb amputation, brachial plexus avulsion injury and spinal cord injury, is usually followed by neuropathic pain. Neuropathic pain is a debilitating condition and it impairs the quality of life profoundly. Based on recent advances in the cognitive neuroscience, we explain intimate relationships among neuropathic pain, reorganization of primary sensory and motor cortices and the sensorimotor integration of the deafferentated limb. From the standpoint of the sensorimotor integration theory for emerging phantom limb pain, we further discuss the analgesic mechanism of neurorehabilitation techniques such as mirror visual feedback treatment and its related neurorobotics advancement for neuropathic pain.

The present report describes a 54-year-old woman with cavernous sinus thrombosis (CST) presenting with fever, and marked periorbital swelling. There is a history of untreated periodontal disease. On initial examination, periorbital pain associated with bilateral blephaloptosis, chemosis, and disturbed eye movement was present. The laboratory evaluation showed significant elevations in inflammatory and fibrinolytic markers. Diffusion-weighted MRI revealed high signal intensities in the bilateral superior ophthalmic veins (SOV). Contrast-enhanced computed tomography (CT) of the cranium showed an enlarged right SOV and a non-enhancing lesion within the right SOV and bilateral cavernous sinus, indicating cavernous sinus thrombosis with diffuse SOV thrombosis. Blood culture performed on admission showed bacterial infection by intraoral resident flora; therefore, the CST was attributed to untreated periodontal disease. Contrast-enhanced CT of the case also revealed the presence of thrombosis in the jugular vein associated with micropulmonary embolus, indicating co-occurrence of Lemierre's syndrome. Antibiotic and anticoagulant treatment were initiated, and the tooth decay was treated; all clinical symptoms and signs subsequently improved. Additional neuroimaging showed that the thrombus was absent from both SOV and the cavernous sinus. Infectious CST is life threatening; therefore, laboratory and imaging examination should be performed quickly, and antibiotic and anticoagulant therapy administrated immediately.

A 57-year-old female developed dizziness and forgetfulness several days before admission. She was admitted to our hospital because of a headache and nausea. On admission, she had a mild disturbance of consciousness and right hemiparesis. Initial MR imaging revealed multiple infarctions in the acute-to-subacute phases in the right cerebellum, left occipital lobe, and bilateral parietal lobes. Her electrocardiogram showed atrial fibrillation and transesophageal echocardiography revealed the presence of a thrombus at the left atrial appendage, suggesting that she suffered from cardioembolic stroke. Laboratory testing showed elevated free T4 levels and low thyroid stimulating hormone (TSH) levels with positive anti-TSH receptor antibodies, indicating untreated Basedow disease. Although treatment with anticoagulants and methimazole was initiated, her postural tremor, tachycardia, and psychosis deteriorated. On the 8th day of admission, thyrotoxic crisis was confirmed. Despite increased doses of methimazole, as well as treatments with inorganic iodine, steroids, and β-blockers, her psychosis prolonged even after her thyroid function was normalized. Long-term use of antipsychotic medications was required to treat her psychosis. In this case, neurotoxicity of the anti-TSH antibodies related to Basedow disease may have caused prolonged psychosis because of the extensive damage to the blood-brain-barrier function following multiple ischemic strokes. Careful observation and treatment are required for psychotic symptoms, in addition to the treatment for acute stroke in such cases, where thyrotoxic crisis is associated with ischemic stroke.

We report the case of a solitary pulmonary tumor, which was diagnosed as recurrent early gastric cancer by detailed pathological examinations. A 59-year old man initially underwent total gastrectomy for gastric adenocarcinoma located at the esophago-gastric junction. A pathological examination indicated a papillary adenocarcinoma (pap ) that had invaded the submucosal layer (sm²), but had not metastasized to the regional lymph nodes (n0). The final diagnosis was P0H0M0T1bN0, Stage IA. Chest computed tomography (CT) 30 months after primary surgery indicated a solitary tumor with a diameter of 9 mm at S3 of the left lung. A positron emission tomography (PET)-CT scan showed an accumulation of ¹⁸F-fluordeoxy-glucose (FDG18) at the same location. Lung cancer was suspected and the patient was given a left upper lobectomy. The resected tumor was diagnosed as gastric cancer metastatic adenocarcinoma by permanent pathological examination. The tumors showed similar histology and immuno histochemical findings for CK7, CK20, TTF-1, SP-A, CDX-2, and HER2 . Early gastric cancer is an almost curable disease and recurrence is very rare. We report the details of this case and review the literature.

The population of elderly individuals who need nursing care is rapidly increasing in Japan. Locomotive syndrome involves a decrease in mobility due to locomotive organ dysfunction, and increases risk for dependency on nursing care service. Because gait speed and chair stand time are correlated with such risks, patients with locomotive syndrome are assessed using brief methods such as the two-step test, which involves dividing the maximum stride length by the height of the patient, and the stand-up test, which involves standing on one or both legs at different heights. One leg standing and squatting are recommended as beneficial locomotive home exercises. Locomotive syndrome has been recognized widely in Japan, and included in the National Health Promotion Movement (2013-2022).

Carotid ultrasound is used to noninvasively assess the structure of the carotid wall as well as flow velocity of the common carotid, internal carotid, and vertebral arteries. The intima-media thickness and carotid plaque evaluated by carotid ultrasound enables us to assess the degree of patients' atherosclerotic change. They have been reported to be closely associated with atherosclerotic risk factors and future cardiovascular events. Furthermore, carotid ultrasound allows us to evaluate large artery atherosclerosis and its flow velocity, which provides information on the cause of acute ischemic stroke. Regarding the comparison of ultrasound findings of carotid plaque with its pathology, plaque with calcification shows the highest echogenicity, with fibrous carotid plaque showing the second highest. On the other hand, atheromatous plaque and that with hemorrhage in it show the lowest echogenicity, indicating the vulnerability of plaques. Furthermore, carotid plaque with ulceration or mobility leads to the occurrence of ischemic stroke.

A 62-year-old woman presented with a right breast tumor. Examination yielded a diagnosis of right breast cancer (T4bN3bM1[lung]). After right breast mastectomy for local control, 9 sessions of chemotherapy containing an anthracycline and taxane were administered. Because of progression of lung metastasis, bevacizumab and paclitaxel were administered. Follow-up computed tomography(CT)scans showed that the multiple solid lung metastases had reduced in size, but a hollowing effect was noted. Eight months later, the patient developed left pneumothorax. The origin of the pneumothorax was unclear, but the hollowing due to the lung metastases seen after bevacizumab treatment was thought to be the cause. The pneumothorax resolved after tube thoracostomy, but disease progression occurred because of the lack of chemotherapy, and the patient's general condition worsened. Although rare, we speculate that there is a risk of pneumothorax after bevacizumab- containing chemotherapy.

An iterative reconstruction (IR) technique in computed tomography (CT) is expected to play an important role in reducing the radiation dose while preserving both spatial resolution and contrast-to-noise ratio. However, images obtained by using the IR technique are known to have different visual appearances from those obtained by using the traditional filtered back-projection (FBP) reconstruction. This appearance is often figuratively described as "blocky," but it has not been objectively characterized further. In this paper, we propose a novel image quality metric, called "perceptual image dissimilarity" (PID), to characterize the visual dissimilarity between FBP and IR images. The PID was formulated as a grayscale transformation and subsequent structural similarity (SSIM)-based image quality measurement. The PID metric was validated using phantom images with three different modules. Sixty datasets, each consisting of an IR image and its corresponding noise-level-equivalent FBP image, were visually assigned "subjective dissimilarity scores" on a five level scale by six observers. The data sets were then quantitatively analyzed using both the PID and the traditional mean squared error (MSE) metrics. Our results show that the PID is highly consistent with the subjective dissimilarity score and thus delivers superior performance, whereas the MSE fails to quantify the observers' visual perception.

Objectives: An outbreak of neurological health disorder caused by drinking well water occurred in 2003 at one apartment building in Kamisu, Ibaraki, Japan. This was the first case of mass poisoning due to well water contaminated with diphenylarsinic acid (DPAA). Subsequently, other residents in Kamisu were confirmed to have drunk well water containing lower concentrations of DPAA. The present study aimed to investigate neurological and other subjective symptoms and miscarriage occurrences after DPAA exposure., Methods: Subjects were residents of Kamisu aged 10-65 years in 2004. Twenty residents (high-level exposure group) had lived in the apartment building and drunk well water containing DPAA at arsenic concentrations of 2,262 μg/L. The moderate/low-level exposure group (67 residents) had drunk other well water containing DPAA at arsenic concentrations of 2-230 μg/L (mean: 85 μg/L) and DPAA was detected in their hair or nails. A control group (134 residents), matched to the latter group by sex and age, had only drunk tap water. Public health nurses completed a questionnaire on symptoms, pregnancy, and miscarriage through interviews., Results: Dizziness, unsteadiness, dysesthesia, writing disturbance, diplopia, insomnia, melancholy, headache, itchiness, weight change, diarrhea, cough, and dyspnea were significantly higher in the moderate/low-level exposure group than in the control group. A similar tendency was found in the high-level exposure group. From 1999 through 2003, no miscarriages occurred among 15 pregnancies in the control group, while three miscarriages occurred among five pregnancies in the moderate/low-level group., Conclusion: DPAA exposure via well water caused miscarriage, in addition to neurological and other subjective symptoms.

A 6-month-old girl with Treacher Collins syndrome was scheduled for tracheotomy because of severe airway obstruction. During slow induction of anesthesia with inhalation of sevoflurane, assisted mask ventilation was successfully performed using oropharyngeal airway. Either direct laryngoscope or GlideScope Video Laryngoscope could not reveal any part of the epiglottis (Cormack and Lehane grade 4). Even fiberoptic bronchoscopic examination assisted by GlideScope Video Laryngoscope gave a poor view of the pharynx on the video monitor. Laryngeal mask airway (LMA) was inserted easily and allowed adequate ventilation, through which fiberoptic intubation was successfully achieved. We cut the LMA short in order to pass the 3 mm tracheal tube until the glottis through it.

We have encountered a case of a patient with bilateral vertebral artery (VA) dissection who suffered from severe pharyngeal pain. A 61-year-old man, who initially visited a nearby hospital for investigation of mild headache, was pointed out to have a left VA aneurysm. The next morning, severe pharyngeal pain on the right side suddenly occurred. The cause was unknown even when consultation was made to an otolaryngology and oral and maxillofacial surgeon. Sore throat improved in two days. On the 12th day after pharyngeal pain, the patient entered our hospital with a diagnosis of VA dissection. Imaging studies indicated severe stenosis of the right VA and an aneurysm of the left VA which confirmed the diagnosis of bilateral VA dissection. After severe stenosis of the right VA improved a little, the trapping of the left VA aneurysm was performed with bypass surgery of the occipital artery to the posterior inferior cerebellar artery. Although there have been reports of glossopharyngeal neuralgia due to compression of dissective aneurysms of VA, no report exists in terms of a sore throat due to VA dissection without glossopharyngeal neuralgia. This symptom was considered to be involved in the referred pain.

An 82-year-old man underwent total gastrectomy(D2 lymph node dissection)in August 2006. The pathological findings indicated T4a, N3, M0, Stage IIIC gastric cancer, but adjuvant chemotherapy was not initiated. In October 2009, he presented to the hospital with dyschezia. During colonoscopy, the scope could not pass through the colon, thus indicating rectal stenosis. The biopsy findings indicated the presence of signet ring cell carcinoma, which was determined to be due to the peritoneal dissemination from the gastric cancer. To avoid the need for creating a stoma, radiation therapy(2 Gy×20; total dose, 40 Gy)and chemotherapy(weekly paclitaxel and S-1)were initiated. Rectal stenosis was improved and complete remission was maintained until May 2013.

A 76-year-old woman visited the hospital for difficulty during swallowing. Endoscopy revealed the presence of an esophageal tumor, and she was referred to our hospital for further examination. A subsequent endoscopy revealed a whole rounded type 3 tumor in the lower esophagus. Computed tomography( CT) scan showed swelling of the lymph node( number 106recL), and no remote metastasis was observed. A diagnosis of Lt type 3, T3N1M0, clinical Stage III esophageal cancer was made, and neoadjuvant chemotherapy( NAC) with 5-fluorouraci(l 5-FU) plus cisplatin( CDDP) was administered. The only side effect noted was grade 1 anorexia. Endoscopy after 2 courses of NAC revealed only scars, and no tumor was detected. CT showed remarkable reduction of the lymph nodes and esophageal wall thickness. Subtotal esophagectomy by right thoracotomy, retrosternal gastric tube reconstruction, and 3-field lymph node dissection were performed. Histopathological examination of the resected specimen revealed the absence of malignant cells in the esophagus and presence of metastasis in the lymph node (Effect 3). Although we have encountered 49 cases of esophageal cancer treated with NAC at our center, this was the first case in which pathologically complete response was achieved. Here, we report a rare case of esophageal carcinoma, which was curatively resected after complete response was achieved following treatment with 5-FU/CDDP as NAC.

Background: Eicosapentaenoic acid-enriched oral nutritional supplements (Prosure®; Abbott Japan, Tokyo, Japan) may attenuate surgical stress and catabolism after gastric cancer surgery. The present study aimed to evaluate the effects of Prosure® on body weight loss( BWL) and compliance with S-1 adjuvant chemotherapy after gastrectomy., Patients and Methods: Patients who underwent curative total gastrectomy for gastric cancer were selected to undergo adjuvant S-1 chemotherapy at Kanagawa Cancer Center between December 2010 and October 2011. The patients received a normal postgastrectomy diet and two 240 mL packs of Prosure® for 21 postoperative days. BWL was defined as %BWL and calculated as %BWL=(preoperative body weight-1-month postoperative body weight)×100/preoperative body weight. Time to S-1 treatment failure was calculated., Results: Five patients were enrolled in this study. The median age was 62.0 years. One patient was male, and 4 were female. The 1-month postoperative BWL was 92.1%. Compared to our previous report, a 20% risk reduction was observed in this study (Prosure® group vs control group, 92.1% vs 89.7%). Moreover, all the patients continued with the S-1 adjuvant chemotherapy for longer than 6 months., Conclusion: Prosure® may inhibit BWL at 1 month after gastrectomy. Moreover, Prosure® improved the patients' compliance with the adjuvant chemotherapy after gastrectomy.

A 45-year-old man was transferred to our hospital because of advanced gastric cancer and peritoneal dissemination. After he received an S-1 plus cisplatin( CDDP) regimen for 6 courses, the primary lesion and ascites had disappeared. However, the primary lesion recurred, and he underwent treatment with 16 courses of an S-1 plus docetaxel regimen. He subsequently developed peripheral neuropathy, and was switched to the irinotecan (CPT-11) regimen. As he experienced appetite loss, it was impossible to continue the chemotherapy. Therefore, he underwent a salvage surgery and an R0 resection was performed. However, 9 months after the surgery, he experienced paraaortic lymph node recurrence and peritoneal dissemination. The patient died 13 months after the surgery.

Purpose: The aim of this study was to evaluate the safety and feasibility of gastrectomy after neoadjuvant chemotherapy in patients with gastric cancer., Patients and Methods: Forty-five patients received neoadjuvant chemotherapy and curative gastrectomy between December 2002 and May 2011. Surgical complications were evaluated according to the Clavien- Dindo classification., Result: The median age of the patients was 63 years. Twenty-three patients received a PTX and CDDP regimen, 20 received an S-1 and CDDP regimen, 1 received an S-1 regimen, and 1 received an CPT-11 and CDDP regimen as neoadjuvant chemotherapy. Distal gastrectomy was performed in 6 patients, and total gastrectomy was performed in 39 patients. The median operation time was 268 minutes, and the median blood loss was 249.5 mL. Complications more severe than grade 2 were observed in 10 patients: anatomic bleeding( grade 3a) was observed in 2 patients; abdominal abscess( grade 2), in 1 patient; and pancreatic fistula( grade 2), in 7 patients. No surgical mortality was observed., Discussion: The results of our study suggest that gastrectomy after neoadjuvant chemotherapy for the treatment of patients with gastric cancer is safe and feasible.

Purpose: The aim of this study was to clarify the human epidermal growth factor receptor 2( HER2) positivity, clinicopathological characteristics, and survival of patients with recurrent HER2-positive gastric cancer who received S-1 adjuvant chemotherapy., Methods: Thirty-eight patients with recurrent gastric cancer who underwent curative D2 surgery and received S-1 adjuvant chemotherapy between June 2002 and December 2011 were examined. HER2 positivity was determined as defined in the ToGA study., Results: The positivity score was assessed by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) as follows: IHC 0 in 27 patients, IHC 1+in 4, IHC 2+/FISH-in 3, IHC 2+/FISH+in 1, and IHC 3+in 3. The HER2 positivity rate was 10.5% (4/38). HER2-positive recurrent gastric cancer was characterized by a differentiated histological feature and frequent blood vessel invasion. However, the recurrence and survival rates were not significantly different between the HER2-negative and HER2-positive tumors., Conclusions: The HER2 positivity rate after S-1 adjuvant chemotherapy did not differ significantly between patients with recurrent gastric cancer and those with primary Stage II/III gastric cancer, suggesting that S-1 adjuvant chemotherapy was equally effective, regardless of HER2 status.

GlideScope videolaryngoscope (GlideScope, herein-after referred to as "GS", Verathon Medical, Bothell, WA, USA), with a high-resolution camera positioned on a blade, enables operators to confirm the position of the larynx and a tube through clear view, thereby conducting intubation safely in a patient whose neck is difficult to be bent back. As the blade is slim, GS is indicated for use in children whose oral cavity is narrow. We herein report safe and smooth intubation with GS in a child with Klippel-Feil syndrome in whom difficult intubation was predicted.