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A 51-year-old man developed acute disturbances in consciousness and psychiatric symptoms one month prior to admission. He was referred and admitted to the Department of Psychiatry of our hospital and transferred to the neurology department because diffuse white matter lesions were found on his brain during MRI. 123 I-IMP-SPECT showed extensive cerebral hypoperfusion mainly in the frontal lobes. Anti-Tg, anti-TPO, and anti-NAE antibodies were positive. These findings led to a diagnosis of Hashimoto's encephalopathy. The patient responded to steroid pulse therapy, high-dose steroid therapy, and intravenous immunoglobulin therapy, showing improvement in symptoms and imaging findings. Hashimoto's encephalopathy often presents with MRI findings similar to those of limbic encephalitis, when the patient presents with acute consciousness disturbance and psychiatric symptoms. However, this case showed diffuse white matter lesions, which may be clinically important for the differential diagnosis.

This interim report presents the results of pleurodesis with 50 ml of 50% glucose solution for patients with inoperable pneumothorax. Twenty patients were enrolled, and treatment was performed for 22 sites in total. The degree of lung collapse was mild in 2 cases, moderate in 12 cases, and severe in 8 cases. The mean number of treatments was 1.4 times (range 1~3). Mild chest pain after injection occurred in one case, and additional chest tube insertion was required for pleural effusion in one case. Other side effects, such as fever or dehydration, were not observed. On day one the mean blood glucose level was 145.0 mg/dl (range 103~259), and the mean pleural effusion volume was 284.6 ml (range 5~910). The air leakage was successfully controlled in 20 of the 22 sites( 91%). Pleurodesis in this manner was thought to be useful intervention for inoperable patients with pneumothorax.

An 84-year-old man was referred to our out-patient clinic with an elongated mass localized to the retrosternal area that was incidentally identified by computed tomography. On 18F-fluorodeoxyglucose-positron emission tomography, this lesion showed intense tracer uptake. Thus, a surgical biopsy under thoracoscopy was performed. Histological examination revealed dense fibrous tissue associated with inflammatory cell infiltration. The immunoglobulin (Ig) G4/IgG plasma cell ratio was over 90%. Serum IgG4 levels were normal. According to the Umehara criteria for IgG4-related disease, a final diagnosis of a "possible" IgG4-related fibrosing mediastinitis was made. Oral glucocorticoid treatment with 30 mg/day prednisolone reduced the mass.

A 42-year-old man complaining of left back pain was admitted to our hospital. The hepatis B and C surface antigens were negative. The serum levels of tumor markers were within the reference ranges. Abdominal ultrasound revealed an 8 cm-sized, primarily round and hyperechoic mass in the left lateral segment. Contrast-echo showed non-uniform enhancement in the arterial phase and uniform enhancement in the portal phase. This mass did not indicate"wash-out"on contrast- enhanced CT. It showed hypointensity in the hepatobiliary phase on MRI. The definitive diagnosis could not be obtained, and the patient was suspected with malignancy, such as hepatocellular carcinoma(HCC). Therefore, left hemi-hepatectomy was performed for the diagnostic treatment. Based on the immunochemical staining results, he was diagnosed with angiomyolipoma( AML). AML is composed of fat, blood vessels, and smooth muscles. It is regarded as a tumor of perivascular epithelioid cell tumor(PEComa). Early venous return and adipose tissues in the tumor were the distinctive features of this tumor. The preoperative diagnosis of AML without any fatty component as in this case is very difficult.

A 69-year-old woman with a hepatocellular carcinoma(HCC)was followed-up for type B chronic hepatitis and underwent partial hepatectomy(S6)at our hospital. Afterwards, she underwent radiofrequency ablation(RFA)therapy twice because of intrahepatic recurrence. Seven months after the first hepatectomy, a left adrenalectomy was performed for a left adrenal metastasis. Seventeen months after the first hepatectomy, a splenectomy was performed for a splenic metastasis. Forty-three months after the first hepatectomy, a second hepatectomy was performed for intrahepatic recurrence, and a right adrenalectomy was performed for an adrenal metastasis. Sixty-eight months after the first hepatectomy, an abdominal CT revealed a growing solitary lesion in the ascending colon, which was diagnosed as a peritoneal metastasis. The peritoneal dissemination was removed because there were no other extrahepatic or intrahepatic recurrences. Histologically, the resected specimen was diagnosed as a peritoneal metastasis from a HCC. The patient survived, and there were no recurrences for 6 months after the operation. We report this case of a peritoneal metastasis from a HCC after surgery with a review of the literature.

A 74-year-old woman visited her local doctor with stomach ache and weight loss. Abdominal ultrasonography showed a mass in the hepatic flexure of the transverse colon. She was referred to our hospital. Colonoscopy revealed transverse colon cancer in the hepatic flexure. Upper endoscopy showed redness of the mucosa and stenosis in the descending portion of the duodenum. Therefore, duodenal invasion was suspected. The CT scan showed a regional lymph node metastasis, but there were no obvious signs of distant metastases. From the aforementioned findings, we diagnosed the patient with duodenal invasion of transverse colon cancer(cT4b, N1, M0, cStage Ⅲ). There was no intraoperative peritoneal dissemination or liver metastasis, and we performed right hemicolectomy and pancreatoduodenectomy for transverse colon cancer. On histopathological examination, we diagnosed pT4b(Duo, Pan), N1b(3/35), M0, pStage Ⅲb. The patient had delayed gastric emptying after surgery. She recovered conservatively and was discharged on POD 37. She underwent adjuvant chemotherapy( capecitabine therapy)and has been alive without recurrence 8 months after surgery. In some cases of colon cancer invasion of other organs, long-term survival can be achieved if R0 resection is possible, and we should consider extended resection.

During the COVID-19 pandemic in 2020, an 81-year-old afebrile woman was transported to our institute at 44 minutes after she was found to have global aphasia and weakness of the right extremities. The onset time was unclear. CT showed an occlusion of the left middle cerebral artery without early ischemic changes. MRI revealed a negative fluid-attenuated inversion recovery (FLAIR) pattern, in which several small acute infarcts were seen in diffusion-weighted images with no corresponding hyperintensity lesions on FLAIR. Accordingly, intravenous thrombolysis with alteplase (0.6 mg/kg, the dose approved in Japan) was administered at 1,660 minutes after the last known well and 116 minutes after the symptom recognition. An immediate internal carotid angiogram showed severe stenosis at the distal end of the horizontal portion of the left middle cerebral artery. In the follow-up angiogram at 164 minutes after the symptom recognition, the stenotic lesion almost resolved with the restoration of quick and nearly complete antegrade flow. Her symptoms also resolved promptly. Although the use of MRI is recommended to be minimized in the emergency stroke management during the COVID-19 pandemic, MRI is occasionally mandatory for patient selection, such as cases with unclear onset to perform intravenous thrombolysis. The individualized protected code stroke is essential and must be well considered by each institute for diagnosing patients by selecting appropriate modalities.

A 65-year-old woman presented with mycosis fungoides and an anterior mediastinal tumor. Stage Ⅱa mycosis fungoides was treated with bath psoralen plus ultraviolet A, topical corticosteroids, and oral bexarotene. One month later, a surgical resection was performed for the anterior mediastinal tumor, which was a stage Ⅱ thymoma with membrane invasion. Furthermore, adjuvant radiotherapy was performed for anterior mediastinum. The mycosis fungoides lesion exacerbated after 3 months;thus, chemotherapies were performed. The patient died of respiratory insufficiency due to multiple pulmonary metastases of mycosis fungoides 1 year after the operation.

In the present study, the usefulness of the resistance-associated variant (RAV) analysis to select direct acting antiviral (DAA) drugs for patients with hepatitis C virus (HCV) genotype/serotype discrepancy was evaluated. The core-genotype and serotype were determined in the 559 patients recruited in the study. The RAV analysis and NS5B-genotype determination were performed in the eight patients who exhibited a genotype/serotype discrepancy. One of these patients exhibited a core-genotype 1b/serotype 2, and detection by RAV analysis was possible in this patient. The other seven patients demonstrated a core-genotype 2/serotype 1, and detection using the RAV analysis was possible in four of them. The NS5B-genotype was 1b in all patients in whom detection using the RAV analysis was possible and was other than 1b in patients in whom detection using the RAV analysis was impossible. The RAV analysis could detect RNA sequences specific to genotype 1b in the NS5A region. Therefore, in patients with genotype/serotype discrepancy in whom detection using the RAV analysis is possible, the treatment regimens should be selected based on the assumption that HCV with genome that is highly homologous to genotype 1b is present in the NS5A region.

A 71-year-old man with anemia, weight loss, and loss of appetite was admitted. Ultrasound examination found thickening of the wall of the stomach. A type 3 gastric tumor was detected in the greater curvature of the gastric corpus via upper gastrointestinal endoscopy. Total gastrectomy, transverse colon resection, and Roux-en-Y anastomosis reconstruction was performed. In the postoperative pathological results, adenocarcinoma, tub2, and diffuse large B cell lymphoma collision was found. The patient underwent chemotherapy for malignant lymphoma and although it was a relatively advanced neoplasia, he is alive without a recurrence.

A72 -year-old woman who complained of abdominal pain and distention visited the emergency clinic of our hospital in April 2014. Computed tomography(CT)showed an omental mass and a pelvic mass with massive ascites. The fluid was removed by abdominal aspiration, and the patient showed perforative peritonitis next day. An emergency operation was performed. The surgical operation showed that the rectum was perforated due to stenosis covered by the ovarian cancer metastases. Aleft colectomy combined with a transverse colostomy was performed. After 4 weeks of rest, 6 courses of tri- weekly TC chemotherapy were administered, and the CA125 level decreased from 140 U/mL to 11.8 U/mL. She underwent a complete cytoreductive surgery in February 2015. She was histologically diagnosed with Grade 2b serous adenocarcinoma. After these 2 surgical operations, she underwent a splenectomy to remove a single metastasis in February 2016 and consecutive chemotherapy. For ovarian cancer, if dissemination occurs, rectal perforation can be a treatment target with a gastrointestinal surgeon's help.

A 36-year-old woman with a left lung tumor was referred to our hospital since a pathological diagnosis had not been obtained at a previous medical institution. We carried out CT-guided percutaneous lung biopsy with an 18-gauge needle and obtained four samples. Immunological staining revealed the specimens to be CD30- and PAX5-positive, with large dysplastic lymphocytes negative for Bob-1 and Oct-2 with a background of small lymphocytes and eosinophils. Primary pulmonary Hodgkin lymphoma (PPHL) was diagnosed. Although PPHL is very rare, it should be included in the differential diagnosis of lung tumors and immunological staining with CD15 and CD30 is recommended. Furthermore, carefully planned CT-guided lung biopsy is useful for diagnosing PPHL.

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.

Aging is a critical risk factor for impaired glucose tolerance and diabetes. In Japan, 8.9 million people are reported to have diabetes, and 37% of those are over the age of 70. In this review, we summarize the current evidence on how aging affects pancreatic beta cell function, beta cell mass, insulin secretion and insulin sensitivity. The pathogenesis of type 2 diabetes (T2DM) in aging is characterized by two major features: impaired insulin secretion and peripheral insulin resistance. Understanding the mechanism that lead to impaired glucose homeostasis and T2DM in the elderly will lead to development of novel treatments that will prevent or delay diabetes, substantially improve quality of life and ultimately increase overall life span.

We introduced an attempt at cancer rehabilitation at Osaka Medical College Hospital. We also reported trends in the clinical department that ordered the cancer rehabilitation, and the days needed to consult the rehabilitation department after hospitalization for 1,028 patients who needed rehabilitation from January to June 2012. The number of rehabilitation orders for cancer patients has increased in comparison with the same period during 2009, and the percentage of cancer rehabilitation orders has also increased, both in total and in each clinical department consulted. In addition, clinical departments that introduced a rehabilitation schedule along with their treatments ordered cancer rehabilitations much earlier than those departments without such a schedule. In future, to start cancer rehabilitation at an earlier stage, we should endeavor to create awareness of the importance of cancer rehabilitation and the introduction of a rehabilitation schedule along with cancer treatments.

Objective: Gadolinium (Gd) contrast-enhanced MRI has recently been introduced to clinical practice to detect endolymphatic hydrops. However, since the image depends on the hardware, pulse sequence or the way of Gd administration, the protocol and the evaluating criteria for hydrops on MRI have not yet been standardized. In this study, we assessed the usefulness of the hydrops detection by MRI following the intratympanic or intravenous Gd administration methods, and compared these findings with the electrocochleography and glycerol test., Methods: MRI was taken in 27 patients with Meniere's disease or delayed endolymphatic hydrops. All patients had frequent episodes of vertigo attacks which were clinically considered as of unilateral ear origin. Two types of Gd administration were used; injection into the tympanic cavity in 17 patients or intravenous injection in 10 patients. Axial 2D-FLAIR images were obtained with a 3.0T MRI unit, 24 and 4 h after intratympanic or intravenous administration, respectively. The endolymphatic space was detected as a low signal intensity area, while the surrounding perilymphatic space showed high intensity with Gd contrast. Those cases in which low signal areas corresponding to the cochlear duct could be clearly noticed, were classified as cochlear hydrops. When the greater part of the vestibule was occupied by a low signal area in more than half of the images, it was classified as vestibular hydrops., Results: Endolymphatic hydrops was detected in 88% (15/17 cases) by the intratympanic Gd administration method, and 90% (9/10) by the intravenous method. In the contralateral ears, 20% (2/10) showed hydrops, detected by the intravenous method. ECochG and the glycerol test were difficult when the hearing of the patient was severely impaired. Positive results of EcochG and the glycerol test were obtained only in 15 and 6 cases, respectively. However, as far as the waves could be obtained, ECochG showed a high detection rate of 88% (15/17) in the affected ear. In those cases in which both MRI and EcochG could be obtained, including both ears, the results were matched in 78% (21/27ears)., Conclusion: For the qualitative detection of hydrops, intratympanic and intravenous Gd administration methods were equivalent. Inner ear Gd contrast-enhanced MRI had higher efficacy in the detection of hydrops than the conventional tests.

The aim of this study was to estimate the tube current on a cardiac computed tomography (CT) from a plain chest CT using CT-automatic exposure control (CT-AEC), to obtain consistent image noise, and to optimize the scan tube current by individualizing the tube current. Sixty-five patients (Group A) underwent cardiac CT at fixed tube current. The mAs value for plain chest CT using CT-AEC (AEC value) and cardiac CT image noise were measured. The tube current needed to obtain the intended level of image noise in the cardiac CT was determined from their correlation. Another 65 patients (Group B) underwent cardiac CT with tube currents individually determined from the AEC value. Image noise was compared among Group A and B. Image noise of cardiac CT in Group B was 24.4 +/- 3.1 HU and was more uniform than in Group A (21.2 +/- 6.1 HU). The error with the desired image noise of 25 HU was lower in Group B (2.4%) than in Group A (15.2%). Individualized tube current selection based on AEC value thus provided consistent image noise and a scan tube current optimized for cardiac CT.

Effective surgical treatment for spontaneous pneumothorax requires control of the postoperative recurrent bulla. Currently, a covering method using an absorbable sheet is a well-recognized form of operative procedure to prevent recurrence. However, the technique used in covering methods appears to be complicated. Here, we present a simple covering method. Using a suture as a guide, we can easily and correctly induce the sheet to the targeting area. Fixation is made at only 1 point at the center of the sheet. To date, we have applied this covering method to 57 patients. Recurrence was recognized in 3 patients( 5.3%) over a mean follow-up period of 12 months.

A 55-year-old man was transferred to our hospital with spontaneous esophageal rupture. An emergency operation of mediastinum drainage by thoracotomy was performed. On postoperative day 8, he had new abcesses located at the upper mediastinum around the esophagus, and required another operation. But one-lung ventilation for the operation was difficult, because of profound hypoxia caused by the acute respiratory distress syndrome (ARDS) with severe sepsis. Therefore we introduced V-V ECMO for the treatment of severe hypoxia and could anesthetize him safely during surgical operation. Intraoperative and post-operative hemodynamics was stable. His respiratory condition improved, and he was weaned from V-V ECMO. Unfortunately, postoperative day 11, he died because of sudden intrathoracic bleeding from the thoracic aorta which might have been infected by the severe mediastinitis.

Recent developments in diagnostic radiology, which have enabled accurate differential diagnoses of brain tumors, have been well described in the last three decades. MR and PET imaging can also provide information to predict histological grades and prognoses that might influence treatment strategies. However, high-grade astrocytomas consist of many different subtypes that are associated with different imaging and histological characteristics. Hemorrhage and necrosis results in a variety of imaging features, and infiltrative tumor growth entrapping normal neurons may cause different clinical manifestations. We reviewed patients with high-grade astrocytomas that showed various imaging characteristics, with special emphasis on initial symptoms and histological features. Clinicopathological characteristics of astrocytomas were also compared with other malignant tumors. Neurological deficits were not notable in patients with grade 3-4 astrocytomas when they showed infiltrative tumor growth, while brain metastases with compact cellular proliferation caused more neurological symptoms. Infiltrative tumors did not show any enhancing masses on MR imaging, but these tumors may show intratumor heterogeneity. Seizures were reported to be more frequent in low-grade glioma and in secondary glioblastoma. Tumor heterogeneity was also reported in molecular genetic profile, and investigators identified some subsets of astrocytomas. They investigated IHD1/2 mutation, EGFR amplification, TP53 mutation, Ki-67 index, etc. In summary, high-grade astrocytomas are not homogenous groups of tumors, and this is associated with the heterogeneity of clinical manifestation, image characteristics, and histopathological findings. Molecular studies may explain the tumor heterogeneity in the near future.

Mycotic stomatitis is one of the most frequent oral complications in cancer patients, but the effects of drug therapy for the disease are unknown. A prospective study was conducted to determine the effects of drug therapy for mycotic stomatitis in hospitalized patients, including cancer patients. ITCZ-OS and MCZ-GEL were used as antifungal agents. Atotal of 104 hospitalized patients were the study subjects for whom the Department of Dentistry was requested to provide dental treatment or oral care by other departments between March and May 20XX. Mycotic stomatitis was seen in 29%(n=30)of the subjects. Among subjects with mycotic stomatitis, 60%(n=18)had cancer, 57%(n=17)received steroids for two weeks or less, 57%(n=17)showed a performance status of 3 or 4, 70%(n=21)had mild to more severe xerostomia, and 53%(n=16)had an unclean oral cavity. As a result of drug therapy, the clinical symptom scores for white coat and flare and the total score were significantly improved on days 3 and 7 compared with before treatment, and the overall improvement rate was 83% on day 3 and 88% on day 7. Many patients hospitalized with mycotic stomatitis have cancer, and it was suggested that drug therapy is effective for them.

Background: The cost of laparoscopic gastrectomy (LG) has not been fully clarified yet., Patients and Methods: The actual cost for the instruments used for surgery was examined between LG and conventional open gastrectomy( OG) by separating distant (l D-) and total (l T-) gastrectomy in a total of 20 patients(5 for each)during Oct 2010 and Feb 2011. The profit was defined as the difference of the actual cost and the operation fee including the instruments determined by the insurance and compared., Results: The fee for D-OG, T-OG, D-LG, and T-LG were 708, 700 yen, 856 , 400 yen, 783 , 600 yen and 922 , 300 yen, respectively. The mean profits of D-OG, T-OG, D-LG, and T-LG were 408 , 297 yen, 475 , 812 yen, 308, 681 yen and 269 , 478 yen, respectively., Conclusion: Appropriate surgical and instrumental fees should be determined considering the actual cost.

During limb skeletogenesis progenitor mesenchymal cells aggregate at specific times and sites to form continuous precartilaginous condensations. With time the condensations undergo chondrogenesis and give rise to cartilaginous anlagen that exhibit incipient synovial joints at each end. A multitude of factors regulates subdivision into discrete skeletal elements and the formation, organization, morphogenesis and structure of the joints. This review summarizes recent advance of joint morphogenesis and actions of key players of joint and articular cartilage formation. In addition, we would like to discuss possible direction to translate basic research findings towards treatment of joint diseases.

We report two cases of otitis media positive for antimyeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) associated with facial palsy. Case 1: A 73-year-old man treated for 3 months for bilateral otitis media with effusion had left facial nerve palsy and deteriorated bone conduction hearing in both ears. Blood analysis showed elevated MPO-ANCA to 134 EU. Case 2: A 66-year-old woman treated for about one year for bilateral otitis media with effusion and fluctuating mixed hearing loss had bilateral facial nerve palsy and a blood test positive for MPO-ANCA at 67 EU. Both were diagnosed with otitis media caused by ANCA-related vasculitis. After prednisolone and cyclophosphamide administration for half a year, blood test results were negative for MPO-ANCA. Both recovered almost completely from facial nerve palsy and bone conductive hearing loss partially improved except in one hearing-impaired ear. ANCA-related vasculitis of the temporal bone should thus be considered in those with intractable otitis media and deteriorated bone conduction hearing before the occurrence of facial palsy.

A 57 year-old woman was admitted for focal accumulation of 18F-fluorodeoxyglucose (FDG) in the liver detected by positron emission tomography (PET). A 25- mm hypovascular tumor was detected by computed tomography. Tumor biopsy revealed many atypical cells with positive staining for factor VIII-related-antigen in sinusoids. Right lobectomy was performed and the tumor was diagnosed as epithelioid hemangioendothelioma (EHE) pathologically. We demonstrated that FDG-PET was useful for the diagnosis of EHE and making deciding on therapeutic strategy.

We report a case of a brain metastasis of thyroid papillary carcinoma. A 50-year-old man suffered generalized convulsion. MRI showed a mixed intensity mass with a perifocal low intensity rim in T2WI, mimicking cavernous angioma. The patient underwent craniotomy and total removal of the mass. The resected specimen revealed thyroid papillary carcinoma. Further examination showed a mass in his thyroid gland. Other distant metastases were not revealed. This is a case of a solitary brain metastasis of thyroid papillary carcinoma and the patient's initial symptom was caused by brain metastasis. Such cases are extremely rare. The mass was presurgically diagnosed as a cavernous angioma but was actually a case of brain metastasis. If we had not performed mass removal, we would not have been able to diagnose it as brain metastasis from thyroid papillary carcinoma and would have not taken appropriate steps toward further examinations and treatment. We must manage carefully a mass resembling cavemous angioma in MRI in consideration of the possibility of its being another diseases such as a metastatic tumor.

Twenty-one patients with unresectable locally advanced pancreatic cancer were evaluated in this retrospective analysis. They received extra-beam radiotherapy(50.4-54 Gy/28-30 fractions)with concurrent continuous infusion of 5-FU(250 mg/m(2)day)between December 1999 and April 2007. The radiation field included primary tumor and adjacent lymph nodes. Twenty patients(95%)completed chemoradiotherapy, although one patient quit radiotherapy due to vomiting. No lethal side effects were observed. The response rate was 10%. One of the patients judged to have stable disease underwent resection after maintenance chemotherapy. The median progression free survival and the median overall survival were 6.4 and 12 months, respectively. In eleven patients(52%), the initial sites of disease progression were local or peritoneum without liver metastases, suggesting systemic effects of this treatment. In conclusion, 5-FU based chemoradiotherapyis well tolerated and provides definite benefits against unresectable locally advanced pancreatic cancer.

Prader-Willi syndrome (PWS) is a genetic disorder, characterized by shorter height, severe obesity and muscular hypotonicity. In particular, sleep disordered breathing (SDB) is a well-known complication in PWS. We encountered one case of PWS, complicated by typical obesity hypoventilation syndrome. A 23-year-old woman had been given a diagnosis of PWS as age 1, therefore she was treated with growth hormone replacement therapy, and with uvulopalatopharyngoplasty (UPPP) for her narrow throat. Her weight increased greatly to 96kg, body mass index (BMI) 51 kg/m2, resulting in hypersomnolence, cyanosis, heavy snoring, and nocturnal awakening. Eventually, she was admitted because of urinary incontinuence and loss of consciousness. On admission, she had severe hypoxia plus substantial hypercapnia, and her chest X-ray film showed severe cardiomegaly with massive pleural and pericardial effusion. On polysomnography (PSG) one week later, her apnea hypopnea index (AHI) was 16 with a mean nocturnal arterial saturation of 74%, mean percutaneous PCO2 59 Torr, which rose to 73 Torr during REM sleep. Non-invasive positive pressure ventilation (NPPV) was initiated, and improved her condition greatly. She was discharged, but continued to recieve NPPV, and her condition has stayed improved.

We reported a case of overlap syndrome involving severe obstructive sleep apnea syndrome (OSAS) associated with chronic obstructive lung disease (COPD). This patient was a 52-year-old heavy smoking man, who had suffered from snoring and apnea for five years, and was admitted to our hospital because of worsening dyspnea. His BMI was 25 Kg/M2, His jaw was very small and he had a narrow upper airway. Chest X-ray showed hyperlucency throughout both lung fields with a markedly dilatation pulmonary arteries. His PaO2 was 62Torr, PaCO2 was 47Torr, FEV(1.0%) was 59%, mean pulmonary artery pressure was 27 mmHg, PSG showed that AHI was 70, were most pronounced during rapid eye movement sleep. He was given a diagnosis of overlap syndrome of OSAS associated with COPD. Generally, Overlap syndrome was believed that chronic bronchitis type (blue bloater) was more frequent than emphysema type. This case was a very rare case, with no obesity, moderate COPD, associated with pulmonary hypertension and hypercapnea, and then to be severe OSAS. However we should be more careful about the OSAS associated with overlap syndrome of the Japanese patients, because to be one factor of exacerbation of respiratory failure.

Clear-cell carcinoma of the ovary is a highly malignant neoplasm. Survival of patients in the advanced stage is poor, and the best treatment is not clear. We report here a case of a 57-year-old woman who had Stage IIIb advanced clearcell carcinoma of the ovary. We performed abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lympho adenectomy and partial omentectomy. After the operation she was placed on induction and maintenance chemotherapy with a combination of irinotecan(CPT-11)(60 mg/m2, day 1, 15)plus cisplatin(CDDP)(60 mg/m2, day 1). Four years after surgery, a metastatic tumor was found in the brain. Considering the poor prognosis of clear-cell carcinoma, this regimen is thought to be effective for advanced clear-cell carcinoma of the ovary. It is important to check brain metastases under maintenance chemotherapy.

Tumors of the parotid gland are fairly frequent among head and neck tumors. Parotidectomy for benign tumors is necessary for diagnosis and therapy. Furthermore, acquiring the skill for this operation is a significant step in the training course of an otolaryngologist Thus, it is useful to analyze the operation time and determine the factors affecting it to evaluate the progress in the operation skill. To measure the operation time and determine the factors affecting it, 71 cases, including 43 cases of pleomorphic adenomas and 28 cases Warthin's tumor, were retrospectively reviewed to the determine if the operation time depended on the age, sex, operated side, presence of complications, BMI, bleeding volume, tumor size, tumor location, exposure of branches of the facial nerve, and experience of the surgeon. Multivariate analysis was used to determine the factors correlated with the operation time. The results revealed that the bleeding volume, tumor size, tumor location and experience of the surgeon were significantly correlated with the operation time, whereas age, sex, operated side, presentation of complications and BMI showed no correlation with the operation time. Furthermore, surgeons with the experience of operating 20-39 cases took almost the same time for the operation as the surgeon with the experience of operating more than 40 cases. Taken together, to shorten the operation time, the inexperienced surgeon should start with smaller tumors and surgery in the superficial lobe in the initial training period, and supervision by well-experienced supervised surgeons is required until 30-40 are undertaken.

Based on a hypothesis that the most effective target area for controlling malignant pleural effusion is the parietal pleura, the author has selectively carried out the multimodality treatment with limited operations combined with parietal pleurectomy (PL) followed by paclitaxel administered by 24-hour intrathoracic infusion and systemic chemotherapy. Seven patients with carcinomatous pleuritis were enrolled in the study. During a median follow-up period of 22 months, malignant effusion was controlled successfully in all patients. Although the imbalance on assessment and small sample size render the results inconclusive, the interim results presented here suggest that the tactic of targeting PL warrants further study in a less-invasive manner.

The comparison study was performed with 3 kinds of Lipo PGE(1) (5 microg/ml) preparations (Formulation A, B, and C), which are now used in clinical. Under alkali condition, Lipo PGE(1) (5 microg/ml) preparations in combination with physiological solution containing calcium ion were susceptible to stop dropping because of the formation of aggregates. There was a difference of feasibility to form aggregates among these preparations. The percentage of PGE(1) in the LM (lipid microspheres) was 68.8% (Formulation A) when determined by filtration with the pore size of 0.1 microm, and the respective value (%) of Formulation B and Formulation C was 43.0% and 13.9%. This indicates that the latter formulations were significantly susceptible to leak from the LM. PGE(1) can induce an extensive irritation. The potency of irritation was the most in Formulation C. This seems similar with the result of LM retention of PGE(1). PGE(1) increased the blood flow. Formulation A reached the peak by 2.27 fold, which was significantly higher than Formulation C and PGE(1) alone (PGE(1)-cyclodextrin, PGE(1)-CD). The peak was also significantly higher in Formulation B than that of PGE(1)-CD. The AUC value of blood flow rate showed a significant increase in Formulation A and Formulation B as compared to that of PGE(1)-CD. Drug retention in the LM can be a determinant factor for drug distribution and pharmacological effect. This study indicates that there can be some differences among Lipo PGE(1) preparations, which have the same drug dose.

Clear cell carcinoma of the endometrium is a very rare and highly malignant neoplasm that accounts for less than 5% of endometrial carcinoma. Survival of patients in the advanced stage is poor, and the treatment of choice is not clear. We report the case of a 62-year-old woman who had Stage IVb advanced clear cell carcinoma of the endometrium with multiple lung metastases. The lesions were considered surgically incurable, so she was placed on neoadjuvant chemotherapy of combination carboplatin (CBDCA) (AUC 5, day 1) plus weekly paclitaxel (PTX) (70 mg/m(2), day 1, 8, 15). After 3 courses of chemotherapy, the uterine tumor was obviously reduced, and lung metastases had disappeared. Therefore, she underwent the operation. The current case suggests that combination CBDCA plus weekly PTX is effective against advanced clear cell carcinoma of the endometrium.

Seven hundred and fifty five cases of acute non-traumatic subarachnoid hemorrhage were admitted to the department of neurosurgery of our hospital from July, 1995 to March, 2004. In 555 patients cerebral angiography was conducted but initial angiography was negative in 30 patients. Except 10 general condition poor patients, in 20 initial angiogram-negative patients were undergone repeated angiography. The cause of SAH could not be demonstrated in 13 cases. The SAH in perimesencephalic and non-perimesencephalic cisturns was seen in 7 and 6 cases, respectively. Occipital and/or neck pain on admission was statistically more common among patients with perimesencephalic SAH than those with non-perimesencephalic SAH (p = 0.029), and the prognosis of perimesencephalic SAH was good. We conclude that repeat angiography should not be recommended in patients with perimesencephalic SAH. Patients with non-perimesencephalic SAH had a higher rate of complication. In the non-perimesencephalic group, 3 patients developed hydrocephalus and 3 patients had vasospasm, which were found by repeated angiography. Therefore, repeated angiography is recommended for better clinical outcome by early detection and management of serious complications in this group of patients.

Chronic sinusitis with eosinophils easily recurs after endoscopic sinus surgery. The condition is usually complicated by asthma, and many eosinophils are present in the sinus mucosa. One conservative treatment method is the administration of glucocorticoids locally or systematically. To evaluate the efficacy and tolerability of intranasal fluticasone propionate for the treatment of chronic sinusitis with eosinophils, seven patients with chronic sinusitis with eosinophils were treated over a 12-week period using a fluticasone propionate aqueous nasal spray (800 microg per day in each nostrilz). The Symptons of 7 patients, especially nasal discharge and nasal obstructions, improved and an expanded air space was observed on paranasal CT images. The percent of drug systemically available after intranasal administration varied by less than 1% for intranasal fluticasone propionate. Therefore, even if intranasal fluticasone propionate is administerved at double the usual dose, it is unlikely to cause systemic side effects. Fluticasone propionate aqueous nasal spray at double the usual dose is effective for the treatment of chronic sinusitis with eosinophils.

Three cases of drug-induced akathisia during palliative care in terminal cancer patients were reported. Antiemetics (metoclopramide and prochlorperazine) possessing a central antidopaminergic effect were suspected to have caused the akathisia. Akathisia, as well as extrapyramidal symptoms, is a common and unpleasant complex neurobehavioral adverse effect of conventional antipsychotic drugs. But it is not widely recognized by general clinicians. This syndrome consists of subjective (feeling of inner restlessness, mental unease, or dysphoria and the urge to move) and objective components (restless movement, including rocking on one's feet, walking in position shuffling and tramping the legs,and crossing and uncrossing one's legs while sitting). In severe cases, patients constantly pace up and down in an attempt to relieve the sense of unrest. While the pathophysiology of drug-induced akathisia remains unknown, antagonism of the mesocortical and mesolimbic dopaminergic pathways is a plausible if not completely satisfactory hypothesis. The notion that dopaminergic blockade underlies the emergence of akathisia is supported by the PET studies. Since akathisia is a drug-induced adverse effect, optimal management involves its prevention rather than treatment. Drugs which have been found to have some efficacy in the treatment of akathisia are anticholinergics, beta-blockers, benzodiazepines and clonidine. Though a number of other treatments have been proposed, no trial-based evidences for treatment of akathisia have been available. It is important that akathisia is recognized and treated appropriately as an adverse reaction to drugs and a further increase in antipsychotic medication dosage may further exacerbate the condition.

The epidemiology of schizophrenia has been studied with regard to the incidence, prevalence, and morbid risk, and there have been comprehensive reviews. However, the incidence and prevalence have not been analyzed simultaneously in many studies. In the present study, which was performed on a remote island, the number of patients could be determined, and they could be followed up by the same observer. This permitted us to conduct comprehensive epidemiological research while providing local mental health care. The subjects were patients diagnosed with schizophrenia according to the DSM-III-R in Tsushima, Nagasaki Prefecture, between April 1, 1988 and March 31, 1996. The incidence of schizophrenia was 2.3 (2.5 in males, 2.1 in females) per 10,000 people of the population, and the age-adjusted incidence was 2.4. Its prevalence was 5.8 (6.1 in males, 5.7 in females) per 1,000 people of the population, and the age adjusted prevalence was 6.2. In both sexes, the number of patients and the prevalence increased annually. The morbid risk was 0.95% (1. 01% in males, 0.89% in females) by the direct method (calculated from the incidence) and 0.85% (0.90% in males, 0.81% in females) by the indirect method (calculated from the prevalence), showing similarity. These incidence, prevalence, and morbid risk results did not markedly differ from the values reported to date. It is important to establish preventive measures for schizophrenia on the basis of the basic data obtained in this study, and to serially evaluate changes in epidemiological parameters of schizophrenia after their application. Furthermore, by comparing these epidemiological findings with those of other mental disorders and other regions, methods are expected to be utilized comprehensively for local mental health care.

This retrospective analysis was undertaken to review our results of treatment of lung cancers with invasion of non-apical and non-vertebral chest wall structures. In summary of our experience, although relatively good prognosis can be expected in N0M0 patients with the histological type of adenocarcinoma by initial operation, distant relapse remains a major problem of the disease. Furthermore, our results are in agreement with the idea that postoperative adjuvant therapy is of little value in patients with complete resection. To ameliorate surgical outcomes, induction treatment should be considered and preoperative staging assessment needs to be strictly done for proper selection of patients with this locally advanced disease. The indication of initial operation needs to be cautiously determined for patients with this disease.

Purpose: To evaluate the systemic effects of intranasal steroid drops in patients with dysosmia., Cases and Methods: Intranasal steroid drops were administered for 12 weeks to 23 patients with dysosmia, and their plasma cortisol and adrenocorticotropic hormone (ACTH) values were measured before and after treatment. Improvement in dysosmia was judged based on the standerd olfactory test and the patients' symptoms., Results: The post-treatment plasma cortisol levels ranged from 0.1 to 25.0 microg/dl (5.4 +/- 5.9 microg/dl), and the posttreatment plasma ACTH levels ranged from 5.0 to 55.0 pg/ml (13.8 +/- 11.7 pg/ml). After treatment, the 23 cases were divided into two groups: 14 cases (60.9%) with a decline in cortisol and/or ACTH level, and 9 patients (39.1%) with normal plasma cortisol and ACTH levels. Improvement in dysosmia was found in 4 patients (28.6%) in the former group and 4 patients (44.4%) in the latter group. The difference in percentage of patients who improved was not significant between the groups., Conclusions: We conclude that the direct topical effect of intranasal steroid drops on the olfactory mucosa may have been the principal reason for the improvement in the patients' dysosmia.

We evaluated the efficacy of perioperative targeting brachytherapy for lung cancer invading the chest wall. Between 1998 and 2003, 7 patients underwent perioperative targeting brachytherapy for lung cancer invading the chest wall. There were 5 male and 2 female patients. The mean age was 63.3 years, with a range of 45 to 77 years. All patients underwent complete resection including the chest wall combined resection. During the operation, plastic afterloading catheters fixed on the Vicryl mesh at interval of 1 cm were placed on the site of chest wall resection. From the third to sixth day after the operation, 15 to 32 Gy of radiation was delivered over 3 or 4 days using a high dose rate remote afterloading system. The area targeted for brachytherapy was determined by a computed tomography (CT) scanner translator with a computer program for radiation planning. The median postoperative hospital stay was 35 days. Local recurrences were observed in 2 patients, but there was no evidence of recurrence in the margin of the resected chest wall. We believe that this short period of treatment and the low side effects enhances the quality of the patients. Prevention of local recurrence was achieved in short term follow-up.

A 12-year-old girl presented with Kasabach-Meritte syndrome associated with anterior mediastinal hemangioma. 111In-oxine-labeled platelet scintigraphy and 99mTc-HSA-D scintigraphy were very useful for the diagnosis and evaluation of this condition.