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The patient was a 27-year-old man. He was referred to our hospital because he was aware of a mass in his abdomen. An abdominal ultrasound showed a 70-mm mass lesion. Enhanced computed tomography showed a 70-mm mass with well- defined margins and heterogeneous internal enhancement near the proximal jejunum. The patient was diagnosed with a suspected primary submucosal tumor of the duodenum or small intestine, and surgery was planned to diagnose and treat the tumor. The tumor was located in the upper jejunal mesentery, and tumor resection and partial small bowel resection were performed. Histopathological examination revealed proliferation of spindle-shaped cells without karyomitosis, and mixed collagen fibers in the tissue. Immunohistochemistry showed β-catenin(+), SMA(+), AE1/AE3(-), KIT(-), CD34(-), and S-100(-). Based on these findings, we diagnosed primary desmoid fibromatosis of the small intestinal mesentery. In this report, we describe a case of primary desmoid fibromatosis of the small intestinal mesentery with a review of the literature.

A 63-year-old woman, who were in a nursing house, visited our hospital with complaints of bloody stools and anemia. Some investigations were performed, CS and CT revealed her diagnosis with sigmoid colon cancer(cT3N0M0)and rectosigmoid adenoma with situs inversus(SI). Laparoscopic low-anterior resection was performed. Postoperative course was good without any complications, and she discharged our hospital at the day 7 after the operation. In surgery, we had to be conscious of mirror image and set operative equipment and operative staffs inversely from normal setting. Some previous reports suggested that some surgical process such as cutting and separating with left hand(non-dominant hand), especially at interior separation, were effective in laparoscopic surgery for SI patients. However, in our operation, we used ultrasonic coagulator with short-pitched incision with surgeon's right hand(dominant hand)instead of left-handed process, and it could be useful for laparoscopic surgery for SI patients. In intrapelvic processes, we proceeded with the surgery as usual because of the symmetric structure of intrapelvic organs. We could complete the laparoscopic low-anterior resection for SI patient with several ingenuity for operative processes.

A total of 306 patients with eosinophilic esophagitis (EoE) were analyzed at our department. Proton pump inhibitors or potassium-competitive acid blockers were used as the first-line treatment in 286 (93.5%) patients. Fifty-five (18.0%) patients received topical steroid swallowing therapy. During 17.7-month mean follow-up, 46.4% of the patients were followed-up with no medications, 37.3% of the patients received maintenance or on-demand therapy using acid-suppressive drugs, and 9.8% of the patients received maintenance therapy with steroid swallowing. The majority of patients with EoE were treated using a therapeutic strategy similar to that used for gastroesophageal reflux disease. However, some patients were refractory to the treatment. Current real-world treatment strategies for Japanese patients with EoE are clarified.

A 70-year-old man was admitted to our hospital with acute abdominal pain. Abdominal CT showed a 6-cm-sized tumor near the third portion of the duodenum, and a duodenal GIST was suspected. Although the abdominal pain was intense and the tumor was suspected to be ruptured, the vital signs were stable; therefore, we initially planned to perform an elective surgery. However, because the pain could not be controlled, the surgery was performed on the 6th day of hospitalization. The tumor appeared to be a duodenal GIST because it was pulling the third portion of the duodenum inwards. It had a strong tendency to infiltrate the surrounding organs; therefore, forced resection of the right colon, which is the surrounding organ, was performed. Pathological findings showed that the resected specimen was a desmoid tumor and the surgical margins were negative. The postoperative course 1 year after surgery was favorable, and no tumor recurrence occurred. We report a case of desmoid tumor, which caused acute abdominal pain.

Basement membrane is a dense sheet-like extracellular matrix (ECM), which separates cells from surrounding interstitium. Type IV collagen is a major component of basement membrane and three of six α chains (namely α1-α6 chains) form a triple-helix structure. Recently, endogenous bioactive factors called "matricryptins" or "matrikines", which are produced by degrading and cleaving C-terminal domain of type IV collagen, attract attentions as a novel therapeutic target or a candidate for biomarkers. In all type IV collagens, matricryptins called arresten (α1 chain), canstatin (α2), tumstatin (α3), tetrastatin (α4), pentastatin (α5), and hexastatin (α6), have been identified. The type IV collagen-derived matricryptins have been previously studied as new therapeutic targets for neoplastic diseases since they exert anti-angiogenic and/or anti-tumor effects. On the other hand, we have recently demonstrated the cardioprotective effects of matricryptins in addition to the altered expression levels in cardiac diseases. In this review, we introduce the results of fundamental studies for the type IV collagen-derived matricryptins in various diseases, such as neoplastic diseases and cardiac diseases, and discuss the potential clinical application as novel therapeutic agents and biomarkers.

The aim of this study was assessment of the laparoscopic surgery after using ileus tube(trans-anal or trans-nasal)for obstructive colorectal cancer compared with non-obstructive cancer., Method: Between April 2010 and March 2019, 129 patients underwent laparoscopic colorectal surgery. 97 patients were non-obstructive colorectal cancer(group N)and 32 patients were obstructive colorectal cancer(group O). Differences between the groups were analyzed using the Mann- Whitney's U-test, as appropriate., Result: In group O, the length of hospital stay was significantly long. There were no significant differences between-group differences in the operation time, estimated blood loss, the rate of conversion to open surgery and postoperative complications., Conclusion: The laparoscopic colorectal surgery is feasible in patients treated with using ileus tube for obstructive colorectal cancer.

Arnold Pick described a focal cortical syndrome caused by focal temporal and/or frontal cortical atrophy, later reffered to as Pick's disease (PiD), a prototype of frontotemporal lobar degeneration (FTLD). In contrast to the current concept of PiD, the presence of Pick bodies (tau-positive inclusions) was not thought to be necessary for the diagnosis of PiD. Four out of the seven patients in his original paper had predominant left temporal atrophy and language related symptoms corresponding to semantic dementia. It is now known that most patients with semantic dementia have transactive response DNA-binding protein 43kDa (TDP-43) pathology rather than tau pathology. The original concept of PiD was substantially similar to the current concept of FTLD, which has heterogeneous molecular pathology including tau, TDP-43 and fused in sarcoma (FUS).

A 48-year-old man was admitted to our department with generalized convulsive seizures followed by recurrent partial clonic convulsions in the left face and arm. Convulsions stopped temporarily after administration of diazepam, fosphenytoin, and levetiracetam. However, frequent partial seizures occurred repeatedly and general anesthesia was required to control seizures. Diffusion-weighted and T 2 -weighted images revealed a high-intensity lesion in the right frontal lobe. A tumor-like area in the white matter showed high intensity on T 2 -weighted images with ring enhancement on gadolinium-enhanced T 1 -weighted images. An area of frontal cortex near the tumor was also enhanced. Brain surgery was performed for the purposes of diagnosis, seizure control and tumor resection. Histological findings demonstrated oligodendroglioma in the ring-enhancing area, but not in the frontal cortex. This fact indicated that contrast enhancement of the frontal cortex was caused by status epilepticus. It is important to recognize that status epilepticus could cause contrast enhancement on magnetic resonance imaging.

The recurrence ofgastric cancer has a poor prognosis in spite ofsystemic chemotherapy. We report three cases oflocal control ofdisease after the recurrence owing to intensity modulated radiation therapy(IMRT). The first case was a 66-yearsold man. He was received distal gastrectomy after neoadjuvant chemotherapy for advanced gastric cancer. Abdominal lymph node metastases appeared 1 year and 7 months after the surgery. IMRT was performed and he keeps CR for 1 year and 8 months. The second case was a 72-years-old man. He received proximal gastrectomy for early gastric cancer. Abdominal lymph node metastasis appeared 1 year and 9 months after the surgery. IMRT was performed and he keeps CR for 1 year. The third case was a 71-years-old woman. She received distal gastrectomy for advanced gastric cancer. Abdominal lymph node metastasis appeared 2 years after the surgery. IMRT was performed and she keeps CR for 10 months. We experienced longtime CR after IMRT against abdominal lymph node metastasis. IMRT could be one ofthe strategies ofthe comprehensive treatment for the recurrence of gastric cancer.

A 51-year-old man was detected nasal bleeding, multiple pulmonary nodule and mass, urinalysis abnormality, renal involvement and high titer of proteinase 3-anti-neutrophil cytoplasmic antibody (PR3-ANCA), and was suspected of granulomatosis with polyangiitis and initiated with steroid pulse therapy. On the day after the start of steroid pulse therapy, generalized peritonitis due to ileal perforation occurred, and emergency ileectomy and peritonitis surgery were performed. Induction therapy with steroid pulse therapy, plasma exchange and intravenous cyclophosphamide therapy (IVCY) and maintenance therapy with glucocorticoid and azathioprine led to good therapeutic outcomes. Gastrointestinal perforation in GPA is a rare complication, and we examined the clinical features, treatment contents, and prognosis of GPA with gastrointestinal perforation from this case and previous reports. Lung involvements were complicated in all reported cases. Gastrointestinal perforations in GPA were frequent in the small intestine, occurred just before and immediately after the start of treatment, and were severe involvement with poor prognosis because of the high mortality rate (46.7%). The frequency of ear, nose and upper respiratory tract lesions in the surviving group was significantly higher than in the dead group (survival 87.5%, death 28.3%, P = 0.041). IVCY were more frequently used in the surviving group (62.5%) than the death group (16.7%), but it was not significantly. GPA complicated with gastrointestinal perforation is a severe condition with poor prognosis, but there is a possibility to improve prognosis by early diagnosis and early initiation of strong treatment.

We developed a method for manufacturing solid models of cerebral aneurysms, with a shorter printing time than that involved in conventional methods, using a compact 3D printer with acrylonitrile-butadiene-styrene(ABS)resin. We further investigated the application and utility of this printing system in emergency clipping surgery. A total of 16 patients diagnosed with acute subarachnoid hemorrhage resulting from cerebral aneurysm rupture were enrolled in the present study. Emergency clipping was performed on the day of hospitalization. Digital Imaging and Communication in Medicine(DICOM)data obtained from computed tomography angiography(CTA)scans were edited and converted to stereolithography(STL)file formats, followed by the production of 3D models of the cerebral aneurysm by using the 3D printer. The mean time from hospitalization to the commencement of surgery was 242 min, whereas the mean time required for manufacturing the 3D model was 67 min. The average cost of each 3D model was 194 Japanese Yen. The time required for manufacturing the 3D models shortened to approximately 1 hour with increasing experience of producing 3D models. Favorable impressions for the use of the 3D models in clipping were reported by almost all neurosurgeons included in this study. Although 3D printing is often considered to involve huge costs and long manufacturing time, the method used in the present study requires shorter time and lower costs than conventional methods for manufacturing 3D cerebral aneurysm models, thus making it suitable for use in emergency clipping.

Objectives: The purpose of this study was to evaluate the appropriateness and usefulness of the first aid training program developed for occupational health nurses (OHNs) to improve their basic skills of first aid treatment., Methods: This was a case-control study. The subjects were 69 nurses who were stationed in workplaces in Japan (intervention group: n=35; waiting-list control group: n=34). The training program was developed using the method of instructional design (ID) and composed of basic life support (BLS) training, basic first aid training, and simulation training. This study was conducted from April to August 2012. The training was evaluated using the Kirkpatrick model of training evaluation: level 1 (reaction), level 2 (learning), level 3 (behavior), and level 4 (results; this level was omitted). For level 1, the training contents were evaluated on a visual analog scale (VAS) of 0 to 10 points on the basis of whether the programs' contents were interesting, understandable, and applicable in the workplace. For level 2, a knowledge test (15 true/false questions) was used. For level 3, the practical application of activities relating to the emergency system was evaluated., Results: There were no significant differences in the attributes and characteristics of the subjects of the workplaces between the intervention and the waiting-list control groups. The score for reaction (level 1) were 8.5-9.7 points. In the knowledge test (level 2), there was no significant difference in the score before training between the intervention (11.0 points) and the waiting-list control groups (11.1 points). However, the score three months later showed a significant difference between the intervention (12.5 points) and the waiting-list control groups (11.0 points). The score after training was significantly higher than the score before the training that the intervention group received. For evaluation of behavior (level 3) three months later, the ratios of implementation of management and review of necessary items, review of task, and discussion with OHNs on emergency systems were significantly high in the intervention group., Conclusions: The evaluation of the first aid training programs for OHNs in this study showed high satisfaction of the participants and indicated improved knowledge and contributions to the waiting-list control group. We consider the contents of the program as appropriate.

Intestinal alkaline phosphatase (IAP) appears in the circulation more frequently in blood group B or O secretors than in blood group A or AB secretors and non-secretors, and serum IAP activity rises following the ingestion of a high-fat meal. In a previous study, the occurrence of two IAP isoforms, with high (HIAP) and normal molecular mass (NIAP), in healthy sera was demonstrated by 6.0% polyacrylamide gel electrophoresis in the presence of 1% Triton X-100. NIAP was present in the fasting serum of only healthy blood group B or O secretors, but was present in all subjects following ingestion of a high-fat meal. We classified 56 healthy subjects into 3 blood groups: B (n = 19), O (n = 17), and A (n = 20), and measured their serum ALP activity in a fasting state and 6 h after a high-fat meal. The amount of ABH substances in the saliva of each subject was determined by the hemagglutination inhibition test. Correlation coefficients between the change in ALP activity after high-fat meal ingestion and the hemagglutination inhibition values in saliva were 0.925 in blood group B, 0.879 in blood group O, and 0.906 in blood group A. These results suggest that increases in ALP activity in the circulation following the ingestion of a high-fat meal are closely related to the amount of ABH substances in saliva.

We report a case of long-term survival of a patient who received low-dose 5-fluorouracil and cisplatin (FP) systemic chemotherapy and underwent partial resection of the lung for a tumor thrombus in the inferior caval vein (IVC) and multiple lung metastases from recurrent hepatocellular carcinoma (HCC). The patient was a 66-year-old man who was admitted to our hospital for the treatment of a 13-cm liver tumor. He underwent an extended posterior sectionectomy of the liver. Pathological diagnosis revealed moderately differentiated hepatocellular carcinoma (vp1, vv1, sm[-, 1.5mm], ch, T3N0M0, stage III). At 3 months postoperatively, computed tomography (CT) revealed a tumor thrombus in the IVC and multiple (>20) lung tumors that were considered HCC recurrences. Low-dose FP systemic chemotherapy was initiated, and the tumors reduced in size. However, a new lesion in the left lung was detected at 13 months postoperatively. Thoracoscopyassisted resection of the tumor that was histologically diagnosed as an HCC metastasis was performed at 26 months postoperatively. The patient is cancer free at 46 months postoperatively. Therefore, low-dose FP systemic chemotherapy is one of the therapeutic options for the treatment of HCC recurrences of IVC tumor thrombi and multiple lung metastases. However, the occurrence of new lesions should be carefully monitored.

A 69-year-old man was admitted to the emergency department 3 hours after ingestion of a bleaching agent containing hypochlorous acid and sodium hydroxide in a suicide attempt. Enhanced chest computed tomography scans taken on admission indicated an edematous esophagus and air bubbles in the mediastinum. He underwent endotracheal intubation and mechanical ventilation until day 9 because of laryngeal edema. On day 10, his endoscopy indicated diffuse reddish mucosal hyperemia, erosions, and lacerated mucosal lesions in the esophagus that were indicative of grade 2b corrosive esophagitis. Treatment with a proton pump inhibitor was initiated, with which the condition of the esophagus improved, and on day 44, a slight stricture of the upper part of the esophagus was observed. He was discharged on day 64 without any complaints. The ingestion of sodium hypochlorite induces corrosive esophagitis and acute phase of gastritis. Ingestion of any corrosive agent is known as a risk factor for esophagus cancer in the long-term. In such cases with esophageal stricture, esophagectomy is recommended for preventing esophagus cancer. Considering the age of the patient, however, he did not undergo esophagectomy.

Neuralgic amyotrophy has been attributed to lesions in the brachial plexus. However, recent studies suggest mononeuropathy multiplex as an underlying pathology at least in a group of patients with neuralgic amyotrophy. We report a man who developed weakness of finger extensors following severe shoulder pain. Neurological examination revealed weakness in the muscles innervated by the left posterior interosseus nerve and the ulnar nerve. We diagnosed him with neuralgic amyotrophy based on the typical clinical course and the neurological and neurophysiological findings. A skeletal muscle MRI revealed abnormal high T2 and STIR signals in the left triceps brachialis muscle, which is innervated by a proximal branch of the radial nerve, and in the muscles innervated by the posterior interosseous and ulnar nerves. The distribution of the denervated muscles suggested that our patient had combined lesions of the peripheral nerve branches rather than the brachial plexopathy. Our report highlights the potential of MRI for detecting denervated muscles in neuralgic amyotrophy.

We report a 39-year-old female admitted for fever. She showed physical findings of bilateral granulomatous uveitis, swelling of the bilateral parotid glands, and paralysis of the left second branch of the trigeminal nerve. Her chest X-ray showed evidence of bilateral hilar lymphadenopathy. We performed biopsy of her parotid gland, and leading to a diagnosis of noncaseating epithelioid granuloma characterized by lymphocyte and multinucleated giant cell invasion. Therefore, she was diagnosed with the abortive type of Heerfordt syndrome which is a subtype of sarcoidosis. This is the only case associated with paralysis of the trigeminal nerve without paralysis of facial nerves to be reported in Japan.

A patient was a 46-year-old man. Multiple lung tumors had been pointed out on a medical examination at age 24. He came to our hospital for further examination. Multiple liver and lung tumors were found out, and epithelioid hemangioendothelioma (EHE) derived from the liver was diagnosed by biopsy. At first we gave recombinant interleukin-2 (rIL-2) by intra-arterial and local injection and then continued it by intramuscular injection for 22 years as maintenance therapy. The tumors have regressed, with partial necrosis. EHE is a rare tumor, but we do not have a standard antitumor therapy except surgical resection. This case suggests that rIL-2 may become a new therapy for EHE. We think that the report of the long-term survival of a case of EHE in which rIL-2 treatment was effective is extremely valuable.

We report a case of emphysematous pyelonephritis coexisting with emphysematous cystitis. A 57-year-old woman seen for abdominal pain, diarrhea, and high fever had been referred after computed tomography (CT) elsewhere had shown an air density mass in the left kidney and pelvis. Abdominal CT on admission showed emphysematous change in the left renal parenchyma and intramural bladder. Serum analysis results showed disseminated intravascular coagulation (DIC) and uncontrolled diabetes. Klebsiella pneumoniae was isolated in the blood. She was diagnosed with sepsis based on these findings due to concurrent emphysematous pyelonephritis and cystitis caused by K. pneumoniae. She was treated conservatively with meropenem, intravenous immunoglobulin, and gabexate mesilate and cured. Concurrent emphysematous cystitis and pyelonephritis is rare., with ours only the fourth case reported in Japan.

To determine the Karp-type Orientia tsutsugamushi subtype in northern Japan, i.e., Yamagata, Niigata, and Akita Prefectures, we analyzed the partial nucleotide sequence of the 56-kDa protein-encoding gene of 30 isolates from scrub typhus cases. Based on sequencing results, we classified isolates into two groups of 27 and 3 isolates. Nucleotide sequences of 27 isolates were homologous to the yeo-joo strain, classified as a JP-1 subtype. The three isolates were each homologous to a stain of CMM1, KNP1, or KNP2, classified as JP-2 subtypes. Phylogenetic tree analysis showed the 27 isolates forming a cluster with the yeo-joo strain and the three isolates with the CMM, KNP1, and KNP2 strains and therefore belonging to these subtypes. The Karp-type O. tsutsugamushi JP-2 subtype predominates in Japan, the JP-1 subtype probably the predominates in the area investigated. O. tsutsugamushi JP-1 subtype strains must therefore be isolated from subjects in this area and comprehensively studied.

The most confusing point in management of the patients with failed back surgery syndrome (FBSS) is that the presence of FBSS is judged not by the objective symptom such as neurological deficit evaluated by medical staff but by the subjective symptom including feeling of pain, disability and satisfaction on medical treatment. In this paper, diagnosis, cause and prevention of FBSS are summarized.

Of 95 Tsutsugamushi disease case occurring in Yamagata prefecture from 1999 to 2006, four-all women-involved the O. tsutsugamushi Kawasaki serotype. The three major symptoms were fever, exanthema, and eschar present from mid-October to early November. Serodiagnosis by indirect immunofluoresence assay showed elevated IgG and IgM antibody titers against the Kawasaki serotype antigen, with IgM higher than IgG. Nested PCR detected 56-kDa DNA in three of the cases. DNA was amplified in Kawasaki-specific PCR. Two cases for which sequencing was done using nested PCR-amplified DNA showed an identity of 99.8% for the Kawasaki strain (Accession number: M63383). These results confirmed the occurrence of Tsutsugamushi disease infection involving Kawasaki serotype in Yamagata prefecture.

A 49-year-old man was admitted to our hospital because of headache, rhinorrhea, and general fatigue. Chest CT revealed some lung nodules bilaterally, and laboratory data were positive for C-ANCA. Brain MRI revealed the findings of pachymeningitis. Wegener's granulomatosis (WG) was diagnosed by the pathological findings of his paranasal sinuses and kidneys. Most of his symptoms remarkably improved with oral corticosteroids and cyclophosphamide. A MEDLINE search about WG with pachymeningitis obtained only 15 cases previously reported in Japan. Considering those reports about WG with pachymeningitis in both Japan and overseas, in some cases pachymeningitis preceded WG, and relatively more cases than normal WG were negative for C-ANCA, furthermore the pathological findings of pachymeningitis were mainly necrotizing granuloma. Therefore pachymeningitis with WG might be mainly composed of granuloma rather than angitis and which might be a expansion of granulomatous inflammation of upper respiratory tract.

We examined water from 182 non-circulating hot spring bathing facilities in Japan for possible Legionella occurrence from June 2005 to December 2006, finding Legionella-positive cultures in 119 (29.5%) of 403 samples. Legionellae occurrence was most prevalent in bathtub water (39.4%), followed by storage tank water (23.8%), water from faucets at the bathtub edge (22.3%), and source-spring water (8.3%), indicating no statistically significant difference, in the number of legionellae, having an overall mean of 66 CFU/100mL. The maximum number of legionellae in water increased as water was sampled downstream:180 CFU/100 mL from source spring, 670 from storage tanks, 4,000 from inlet faucets, and 6,800 from bathtubs. The majority--85.7%--of isolated species were identified as L. pneumophila : L. pneumophila serogroup (SG) 1 in 22%, SG 5 in 21%, and SG 6 in 22% of positive samples. Multivariate logistic regression models used to determine the characteristics of facilities and sanitary management associated with Legionella contamination indicated that legionellae was prevalent in bathtub water under conditions where it was isolated from inlet faucet/pouring gate water (odds ratio [OR] = 6.98, 95% confidence interval [CI] = 2.14 to 22.8). Risk of occurrence was also high when the bathtub volume exceeded 5 m3 (OR = 2.74, 95% CI = 1.28 to 5.89). Legionellae occurrence was significantly reduced when the bathing water pH was lower than 6.0 (OR = 0.12, 95% CI = 0.02 to 0.63). Similarly, occurrence was rare in inlet faucet water or the upper part of the plumbing system for which pH was lower than 6.0 (OR = 0.06, 95% CI = 0.01 to 0.48), and when the water temperature was maintained at 55 degrees C or more (OR = 0.10, 95% CI = 0.01 to 0.77). We also examined the occurrence of amoeba, Mycobacterium spp., Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus in water samples.

A 57-year-old man was admitted to our hospital because of dyspnea and right abdominal pain. Chest X-ray radiogram showed right massive pleural effusion. Ultrasonic echogram of abdomen showed a unilocular liver cyst. He was treated with intravenous infusion of meropenem, and percutaneous pleural and liver drainage were performed. At the time of drainage, we injected contrast medium into the liver cyst and confirmed a fistula connecting to the right pleural space. Initially we made a diagnosis of bacterial empyema and liver abscess, yet there was no response to the initial treatment. Cultures of pleural effusion and liver abscess were confirmed to be negative. A few days after admission, the patient stated that he was a homosexual. Liver amebiasis and its perforation became the most likely diagnosis, and metronidazole was administered. On admission day 21, tests for anti-amebic antibody were positive. Finally he fully recovered. We must be aware of the rare pulmonary manifestation of amebiasis. We report this case and review the literature.

A 57-year-old man was admitted to our hospital because of low-grade fever and pain in the right hypochondrium. Abdominal ultrasonographic (US) examination revealed a hyperechoic mass in the body of the gallbladder. The wall of the gallbladder towards the fundus was markedly thickened, while the wall near the gallbladder neck showed no abnormality. Power Doppler and contrast-enhanced CT of the abdomen revealed absence of blood flow in the fundic wall of the gallbladder, however, a contrast-enhanced image of the entire wall was obtained by contrast US, although the blood flow to the fundus was decreased. Torsion of the gallbladder was diagnosed and laparoscopic cholecystectomy was performed. The gallbladder was found to be a wandering gallbladder, Gross I type, and slight counterclockwise torsion was found at the neck of the gallbladder. We report a case of partial torsion of the gallbladder neck, in which the details of the ischemic hemodynamic changes could be observed by contrast-enhanced US.

Nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA) occurred at a major in Yamagata prefecture hospital between May 2004 and June 2005. We studied pulsed-field gel electrophoresis patterns, antimicrobial susceptibility patterns, and bacteriological features, such as coaglase type for eight isolates, including two of methicillin-resistant Staphylococcus epidermidis (MRSE). Our results suggest that this case was caused by a single strain of multidrug-resistant S. aureus. These 8 clinical isolates indicated reduced susceptibility to vancomycin and teicoplanin. PCR assay results for detection of the staphylococcal vanA, vanB, and vanC gene were all negative as all isolates. In transmission electron microscopy, cell walls appeared thicker than those of a susceptible strain from food poisoning. MRSA with reduced susceptibility to glycopeptide antibiotics may not be treated successfully with vancomycin or teicoplanin, making it important to closely observe MRSA with reduced susceptibility to glycopeptide antibiotics.

We encountered 4 cases of hepatic peribiliary cysts (HPBC) in our hospital. Two were asymptomatic, one was complicated by a choledocholithiasis, and one by cholangitis and sepsis. Based on a review of the 38 cases of HPBC clinically diagnosed in Japan, the main problem associated with this disease seemed incorrect preoperative diagnosis leading to an unnecessary hepatectomy. Another problem was concomitant cholangitis, which tended to recur and in some cases needed aggressive treatment using drainage.

Many types of block are used for treatment of low back pain. In the current paper, trigger-point block, facet block, ilio-sacral joint block, epidural block and nerve root infiltration (nerve root block), quite common procedures for treatment of low back pain, are introduced and technical notes are described. There are two important points for block treatment, one is the knowledge of anatomy and another is the knowledge of side effects. We must remember to prepare everything for side effects when block treatment is done.

Objectives: This study investigated the influence of imaging method, acoustic power, and dose of contrast agent on the occurrence of premature ventricular contraction during myocardial contrast echocardiography., Methods: Myocardial contrast echocardiography was performed with a Toshiba POWER VISION 6000 and YM454 (Definity in USA) contrast agent. Myocardial contrast echocardiography in the short-axis view at the mid-papillary muscle level and electrocardiography in lead II were recorded on videotape in nine awake beagles. The imaging method was continuous, using 1:1 and 1:4 intermittent end-systolic triggered mode. Acoustic power was low, middle and high (as mechanical index, 0.4, 0.8 and 1.0 at continuous mode and 0.6, 1.0 and 1.4 at intermittent mode). YM454 was given intravenously at doses of 1, 10, 30, 50 and 100 microliters/kg/min. Premature ventricular contractions were counted on the videotape for each experimental condition. The examination was repeated on a separate day to ascertain the reproducibility., Results: At low and middle acoustic power, no premature ventricular contraction was induced with any combinations of YM454 doses and trigger intervals. The highest incidence of premature ventricular contraction was 5.1% of all ultrasound pulses at the combination of high acoustic power, 1:4 intermittent and 30 microliters/kg/min of YM454. All premature ventricular contractions induced by trigger mode were observed concomitantly to the end-systolic phase. Reproducibility was low at 0.9%., Conclusions: Although high acoustic power, intermittent myocardial contrast echocardiography with high dose of contrast agent induced premature ventricular contractions, the incidence of premature ventricular contractions was low. Low acoustic power or low dose of contrast agent induced no premature ventricular contractions.

Cytochrome P450(CYP)3A4 is one of the CYP enzymes catalyzing oxidative metabolism, and involved in the metabolism of many drugs. Among benzodiazepines, alprazolam, triazolam, brotizolam and midazolam are mainly metabolished by CYP3A4, and quazepam, diazepam and flunitrazepam are partly metabolised by this enzyme. Azole antifungals, macrolide antibiotics, calcium antagonists and grapefruit juice inhibit CYP3A4 activity, while antiepileptics and rifampicin induce the activity. The drugs affecting CYP3A4 activity inhibit or induce the metabolism of the benzodiazepines metabolised by this enzyme, and induce side effects or reduce therapeutic effects of these drugs. Therefore, the combination of the two groups of drugs should be avoided, and if it is unavoidable the dose of benzodiazepines should be adjusted.

Background and Objectives: The fate of blood trapped inside the myocardial microvessels after complete occlusion of the coronary artery has not been elucidated. Blood may be squeezed out by residual contraction even after coronary occlusion. The microcirculation was examined soon after coronary occlusion by real-time contrast echocardiography., Methods: Myocardial opacification in the short-axis view was examined during infusion of FS69 (Optison) using the Coherent Contrast Imaging method(SIEMENS Sequoia 512) in 17 open chest dogs. The left circumflex coronary artery was completely ligated for 15 sec and the video intensity (256 gray level) of the risk area was measured at end-systole of every 3 beats before and after ligation. Temporal deterioration of the wall motion was evaluated, defined as normokinesis, mild hypokinesis and severe hypokinesis, and akinesis. Changes in the video intensity during each stage of wall motion abnormalities were examined., Results: The video intensity of the risk area decreased significantly after coronary occlusion. Wall motion of the risk area deteriorated gradually after ligation, in which mild hypokinesis, severe hypokinesis and akinesis developed consecutively at 2.8 +/- 0.5, 5.4 +/- 0.5 and 7.8 +/- 0.8 sec after coronary ligation, respectively. The changes in video intensity during each stage of the wall motion abnormalities were small and not statistically significant, irrespective of severity of wall motion abnormalities., Conclusions: These findings suggest that the blood remains in the vascular bed immediately after the coronary occlusion and is not squeezed out even if wall motion of the risk area continues.

In order to see the patients with low back pain and/or sciatica, it is most important to consider the pathophysiology of symptoms. We should know that the image findings such as X-ray and MRI do not always show the cause of symptom. Because degenerative changes in lumbar spine are common findings in asymptomatic group compared to symptomatic patients with low back pain and sciatica. According to pathophysiology (nerve root syndrome, cauda equina syndrome, facet syndrome, discogenic pain syndrome and intermittent claudication for low back pain), the treatment for low back pain and sciatica were described.

Single photon emission tomography (SPECT), MRI and EEG were studied in two infants with lissencephaly. One infant had generalized tonic convulsions at 7 month of age and continuous high voltage fast activities on EEG. The other infant developed infantile spasms at the age of 2.5 months, and showed low voltage disorganized background with pseudorhythmic high voltage sharp waves on EEG. Cranial CT and MRI in both infants revealed abnormally thick cortex, dilatation of the lateral ventricles, and smooth or relatively smooth cerebral surface. In SPECT studies, a diffuse increase of tracer uptake was shown at the cerebral cortex compared with the basal ganglia or cerebellum in both infants. The SPECT finding might reflect the abnormal cortical architectures in this cerebral malformation.

Clinical and electroencephalographic (EEG) studies were performed in two children with hemimegalencephaly. The ages of seizure onset were 44 hours after birth in one infant and 33 days of postnatal life in the other patient. In both children, infantile spasms (IS) associated with hemihypsarrhythmia, developed at 1.5 months and 4 months, respectively. The subsequent clinical courses in these children were notable for frequent, intractable seizures. The seizures consisted of either generalized or partial seizures which originated from not only the hemimegalic hemisphere but also the contralateral one. Later, the clinical and EEG findings in one child indicated the development of Lennox-Gastaut syndrome (LGS). These findings suggested that the lesions of epileptogenesis in patients with hemimegalencephaly involved not only the pathological hemisphere, but also the contralateral hemisphere and subcortical structures. A detailed neurophysiological investigation in hemimegalencephaly could help the elucidation of the pathophysiology of intractable epilepsies, such as IS or LGS.

A 4-year-old girl with Guillain-Barré syndrome (GBS) showed the abnormal enhancement on MRI in the anterior nerve roots corresponding to the region of her muscle weakness on the 26th day of illness. The enhancement on MRI almost disappeared on the 89th day of illness, when her symptoms had more improved. We think that enhanced spinal MRI is useful to reveal the involved nerve roots and the degree of the illness in GBS.

Sixty-seven years-old female, who was an atomic bomb survivor in Hiroshima, was pointed out as having leukopenia and anemia in 1991. She was referred to Tsukuba University Hospital in June 1992. Her peripheral blood count showed pancytopenia- 2,600/microliters WBC, 10.5 g/dl hemoglobin, and 80,000/microliters platelets- at that time. BM biopsy revealed hypoplastic marrow and increased peroxidase-negative blasts (32.8%). Surface marker analysis of the blasts showed a feature of CD2+ CD33+ CD34+ CD13+ CD3-. Electronmicroscopically, myeloperoxidase was positive. She was diagnosed as having hypoplastic leukemia of which the blasts had a feature of AML-M0 by FAB-group. After 6 months' silent period, her pancytopenia became profound. We successfully reduced the blasts by BAM therapy. However, she died of bacterial pneumonia during the myelosuppressive state. This is a case of minimally differentiated hypoplastic AML.

A girl aged 1 year and 2 months with hypomelanosis of Ito was reported. She suffered from intractable epileptic seizures since the second day after birth. Characteristic bizarre hypopigmented skin lesions were seen on her left shoulder and extended in a linear fashion to the flexion side of the left upper extremity. Brain MRI revealed diffuse enlargement of the left hemisphere, dilatation of the left lateral ventricle, and neuronal migration anomalies, indicating hemimegalencephaly. The types of her seizures were secondarily generalized or unilateral initially, followed by infantile spasms at 1.5 month. Around 4 months of age, frequent partial seizures appeared. Her seizures were intractable despite vigorous anticonvulsant therapy. As patients with hypomelanosis of Ito are frequently associated with neurological abnormalities, brain MRI studies were thought to be essential in detecting central nervous system anomalies, particularly in the presence of early onset intractable seizures.

A 64-year-old female was admitted to our hospital with the complaints of chest oppression and dyspnea, 3 months after the traffic accident. She was operated on with the diagnosis of aortic regurgitation and bicuspid aortic valve. The tear of aortic valve was detected in the anterior cusp, and the size of the tear was 12 mm. The aortic valve replacement was performed and her postoperative course was uneventful. In the pathological study of the cusps, the tear was originated from trauma without inflammatory changes. This is the first report of traumatic rupture of the bicuspid aortic valve in Japan.