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Learning is classified into two types: "classical conditioning," which modifies simple reflexes, and "operant conditioning," which modifies complex voluntary behaviors. The neural circuits underlying these two types differ significantly. During the learning process of operant conditioning tasks, various changes in firing rate and firing synchrony of neurons can be observed across multiple brain regions. Additionally, neuronal firing rate and synchrony in several brain regions can be voluntarily controlled through operant conditioning. Consequently, it is evident that neurons in widespread brain regions have the potential for plastic changes to facilitate learning. It may be suggested that the learning of complex voluntary behaviors is underlined by widespread dynamic changes in neural activity and is not restricted to only a few brain regions.

A 65-years-old man undergoing hemodialysis for chronic kidney disease was diagnosed with ascending colon cancer and 3 hepatic metastases. He was administered mFOLFOX6 (reducing the dose to 50%) plus bevacizumab (BEV) therapy. Hemodialysis was performed 4 h after administration of oxaliplatin on day1 and repeated three times a week. No serious adverse events were observed. After 4 courses of chemotherapy, a computer tomography scan showed that the hepatic metastases had reduced. 2 courses of mFOLFOX6 (increasing the dose to 75%) plus BEV therapy were added, he was operated by laparoscopic right hemicolectomy and laparoscopic patrial hepatectomy. He has been in remission for 2 years and 4 months since the surgery. Dose-adjusted chemotherapy with hemodialysis was effective and improve the prognosis of the patient.

An 86-year-old woman was referred to our hospital after an incidental CT scan of the trunk revealed a mass in the left breast and enlarged axillary lymph nodes. A core needle biopsy(CNB)from a 2 cm mass in the left breast revealed invasive ductal carcinoma, weakly positive result for ER, negative result for PgR, and negative result for HER2. She also had multiple enlarged left supraclavicular lymph nodes and was T2N3cM0, Stage ⅢC on pretreatment evaluation. She was given the S-1 oral drug of choice, starting with 80 mg/day/4-week dosing with a 2-week rest. Eight months after the start of S-1, a partial mastectomy and sentinel lymph node biopsy were performed. Pathological findings showed a pathological complete response(ypTis/ypN0)with only a 2 mm non-invasive carcinoma remnant in the left mammary gland. S-1 is weakly recommended as primary chemotherapy for HER2-negative metastatic recurrent breast cancer, but there are no reports to date of complete response in resection cases. S-1 may be administered to patients with locally advanced breast cancer who cannot tolerate standard drug therapy and may be converted to resection after a successful response.

A 48-year-old male patient with a history of alcoholic cirrhosis was admitted to our hospital due to hematemesis with a 7-day history of melena. Emergency esophagogastroduodenoscopy revealed esophageal variceal bleeding. We attempted hemostasis with endoscopic variceal ligation (EVL). The esophageal mucosa was not aspirated into the EVL device although the patient had no history of endoscopic injection sclerotherapy or EVL. Percutaneous transhepatic obliteration (PTO) was performed and esophageal variceal bleeding was successfully hemostasis. PTO is a viable option for refractory esophageal bleeding.

This is a case of a 61-year-old female who presented to our hospital with liver dysfunction without any symptoms. She was diagnosed with splenic arteriovenous fistula. About 8 months later, she visited the hospital again due to abdominal distention and diarrhea. Computerized tomography (CT) revealed splenic aneurysm, dilated splenic vein enhanced in the arterial phase, ascites, and intestinal edema. We considered that these findings were caused by portal hypertension due to splenic arteriovenous fistula. The splenic aneurysm was managed with coil embolization. Completion arteriography revealed the absence of flow into the splenic arteriovenous fistula. Surveillance CT scans at 2 months post-procedure confirmed complete occlusion of the aneurysm and arteriovenous fistula. There was no evidence of splenic infarction. The patient remained asymptomatic 1 year post-procedure. Asymptomatic splenic arteriovenous fistula is rare and needs immediate treatment due to the high probability of deterioration.

A 70-year-old patient who survived about 40 years after left pneumonectomy for tuberculosis visited emergency hospital, because of dyspnea. She received suitable medical therapy for atirial fibrillation and severe mitral regurgitation and hesitated heart surgery because of anxiety for surgical risk. The computed-tomography showed mediastinal shift to left and right lung compensatory expansion. Respiratory function test after treatment of heart failure showed only mild restrictive disorder. And the blood-gas examination in room air was 101 mmHg of Pao2 and 37 mmHg of Paco2. The mitral valve replacement was performed via median sternotomy and using normal cardiopulmonary bypass. And she fully recoverd without any respiratory complications. Mediastinal shift did not obstract the surgical view and establishment of cardiopulmonary bypass in this case. It seemed that the key of surgical successs is the preserved function of healthy residual lung.

Cyanogenic glycosides in loquat (Eriobotrya japonica) seeds, which are used in so-called health foods, pose a public concern in Japan due to their potential health risks. Several pretreatment methods, such as the steam distillation and Conway microdiffusion methods, have been established for the determination of cyanogenic glycoside concentrations in foods. However, these methods are time-consuming and have extremely low throughput. Therefore, we developed a simple and rapid method, called the purge method, to analyze cyanide compounds in seed-derived food products. Under this method, the aqueous extract of cyanogenic glycosides is treated with β-glucosidase in a midget impinger, after which the liberated cyanide is purged into an absorbing solution. The concentration of cyanide in the adsorbent is then quantified using 4-pyridinecarboxylic acid-pyrazolone reagent. A single-laboratory method validation study was performed using amygdalin at a concentration of 10 ppm as cyanide ion. The validation parameter results (trueness, 83.9%; repeatability, 1.18%; intermediate precision, 4.67%) indicated that the developed method was suitable, precise and accurate. The purge method was used to analyze cyanide concentrations in commercially available food samples. Of the 10 samples tested (loquat seed powder, apricot kernel powder, and plum seed powder), three samples were found to contain cyanogenic glycosides at concentrations of >10 ppm as hydrogen cyanide, with the highest concentration detected being 861 ppm. These results clearly demonstrated the applicability of our method in determining cyanogenic glycosides in seed-derived food samples.

Case 1: A 48-year-old female was admitted to our hospital because of left HER2 type breast cancer with a skin invasion of 10×11 cm in the chest wall. Since she had previously received anti-HER2 therapy, we performed anti-HER2 therapy in our department as well, but the tumor gradually became larger and presented with a cancerous ulcer. The use of metronidazole gel in the tumor area reduced the odor. The tumor progressed and she died 1 year and 1 month after the first visit to our hospital. Case 2: A 51-year-old female visited our hospital because of a cauliflower-like right breast tumor measuring 20×17 cm with bleeding and infection. After diagnosis of right breast cancer with multiple bone metastasis, CMF therapy was performed, and then 40 cycles of docetaxel and bevacizumab therapy were performed. As a result, her breast tumor is no longer visible macroscopically, and she runs her daily life without problems. Breast cancer with an extensive skin invasion has a poor prognosis. However, in some cases such as case 2, the proper chemotherapy might be beneficial for long survival.

Thoracic endovascular aortic repair (TEVAR) has become a major procedure for thoracic aortic aneurysm and its indication is expanding. On the other hand, TEVAR specific complication is rather critical and its treatment is of increasing interest. Especially, open repair after TEVAR is sometimes demanding and case based strategy is mandatory. We experienced a case of open repair for aneurysm infection and endoleak after fenestrated TEVAR in 76-year-old man. He underwent initial aneurysmal repair using fenestrated graft 2 years ago. Five months later, debridment of infected tissue was performed because of aneurysmal infection. Type Ⅰ endoleak appeared after the surgery and expansion of the aneurysm made us decide extensive open repair. The operation was done under hypothermic circulatory arrest and selective cerebral perfusion. Partial removal of stent-graft and insertion of the open stent-graft, replacement of ascending aorta and reconstruction of neck vessels were done. Postoperative course was smooth. Open repair after TEVAR is often demanding. Sophisticated strategy for each case has to be planned.

An 83-year-old woman was injured in a traffic accident. Enhanced computed tomography (CT) showed aortic injury on the isthmus, Stanford type A aortic dissection and intracranial hemorrhage. Neurological deficit was not noted. We immediately started to lower the blood pressure, and her hemodynamic status remained stable. Although intracranial bleeding had not worsened on the next day, a false lumen of the aortic arch was newly enhanced on CT. Emergency total arch replacement with frozen elephant trunk was performed under deep hypothermia and selective cerebral perfusion. Intraoperative angiography showed no endoleak at the descending aorta. Postoperative course was uneventful, and the patient was discharged on the 21st postoperative day. This procedure is useful for aortic injury involving the ascending aorta and the arch.

The patient was a 78-year-old man who had undergone left lung segmentectomy (S6) with lymph node dissection for lung adenocarcinoma. One year and 5 months later, lung partial resection was performed for the lung cancer recurrence and the hematemesis was noted on the next day of surgery. Upper gastrointestinal endoscopy revealed extensive black necrosis on the mucosa of the esophagus, which was diagnosed as acute necrotizing esophagitis. To treat the bleeding, the exposed esophageal vessels were clipped via endoscopy several times. The endoscopy on the 64th post-operative day showed the mucosa recovered and he could be discharged on the 85th day. The exact etiology of acute necrotizing esophagitis is unknown in most cases.

A 70-years old man was referred to our department for acute heart failure due to post myocardial infarction papillary muscle rupture. We planned emergent surgery, but he refused blood transfusion because of religious reason( Jehovah's Witness). Therefore, we chose medical therapy using intra-aortic balloon pumping and catecholamine. He was also treated with subcutaneous erythropoietin and intravenous iron supplement to increase preoperative hemoglobin. One month later, we decided to undergo mitral valve repair because he was stabilized with medical treatment. The patient underwent mitral valve repair with artificial chordae through median sternotomy. The mitral valve A3 prolapse was caused by posterior papillary muscle rupture. No blood transfusion was given and postoperative course was uneventful. We experienced successful mitral repair for post infarction papillary muscle rupture in a Jehova's Witnessess patient.

An 81-year-old woman who presented with chest and back pain was diagnosed as aortopulmonary fistula caused by rupture of an aortic arch aneurysm and was transferred to our hospital for surgical treatment. Additionally, she was diagnosed with aortic dissection( Stanford type B). Total arch replacement with open stent-grafting and direct closure of aortopulmonary fistula were performed because of her exacerbation of congestive heart failure. Manual compression of fistula during cardiopulmonary bypass was effective to control massive shunt. The patient recovered uneventfully and was transferred to other hospital for rehabilitation on postoperative day 24.

The tumor microenvironment plays a key role in cancer progression, drug resistance, metastasis, etc. To establish a new therapeutic strategy based on control of the tumor microenvironment, I have developed a lipid nanoparticle (LNP)-based in vivo small interfering RNA (siRNA) delivery system equipped with a targeting ligand. First, I established an LNP that induces membrane fusion in response to acidification after internalization by cells using the original pH-sensitive cationic lipid YSK05. A modification of polyethylene glycol to YSK05-containing LNPs allowed significant gene silencing in the human renal cell carcinoma model. Then, I attempted to establish a tumor vasculature-targeting LNP because the vasculature is responsible for the tumor microenvironment. Cyclic RGD peptide is known to be a ligand against integrin αVβ3, which is highly expressed on tumor endothelial cells (TECs). Optimized cyclic RGD peptide-modified LNP (RGD-LNP) suppressed gene expression in TECs to 50%. The inhibition of vascular endothelial cell growth factor receptor 2 (VEGFR2), which is a dominant factor in angiogenesis, by the injection of RGD-LNP significantly delayed tumor growth. Finally, I examined the effect of RGD-LNP on the tumor microenvironment. The suppression of VEGFR2 increased pericyte coverage and endothelial junctions, which indicate maturation of the vasculature. In RGD-LNP-treated mice, systemically administered nanoparticles encapsulating doxorubicin were distributed in a larger area than in untreated mice. Moreover, the therapeutic effect of doxorubicin-loaded liposomes was significantly enhanced by RGD-LNP. In conclusion, I succeeded in developing a new therapy based on regulation of the tumor microenvironment.

The anatomy and function of the angular gyrus (Brodmann Area 39) and supramarginal gyrus (Brodmann Area 40) are described here. Both gyri constitute the inferior part of the parietal lobe. Association fibers from the angular gyrus project to the dorsolateral prefrontal cortex via the superior longitudinal fasciculus (SLF) II/arcuate fasciculus (AF), whereas those from the supramarginal gyrus project to the ventrolateral prefrontal cortex via SLF III/AF. Damage to the left angular gyrus causes kanji agraphia (lexical agraphia) and mild anomia, whereas damage to the left supramarginal gyrus causes kana alexia (phonological dyslexia) and kana agraphia (phonological agraphia). Damage to either gyrus causes Gerstmann's syndrome (finger agnosia, left-right disorientation, agraphia and acalculia) and verbal short-term memory impairment. "Angular alexia with agraphia" results from damage to the middle occipital gyrus posterior to the angular gyrus. Alexia and agraphia, with lesions in the angular or supramarginal gyrus, are characterized by kana transposition errors in reading words, which suggests the impairment of sequential phonological processing.

Sjögren-Larsson syndrome (SLS) is an autosomal recessive disease characterized by a triad of congenital ichthyosis, spastic quadriplegia and mental retardation. An 11-year-old girl (body weight 30 kg) diagnosed as SLS was admitted with Benett fracture of the right thumb. She was monitored with standard protocol. General anesthesia was induced by rapid induction method with propofol 50 mg and rocuronium 0.6 mg - kg⁻¹. She was ventilated with bag and mask, and intu- bated without difficulty. Neuromuscular function was continuously assessed by 40 mA-TOF-stimulation re- sponses with acceleromyography immediately after induction of general anesthesia by TOF-Watch® SX (Organon Ireland, division of MSD, Ireland). Anesthe- sia was maintained with total intravenous anesthesia with propofol 6-8-10 mg⁻¹ · hr⁻¹ in oxygen. No abnor- mal responses were observed by TOF-Watche SX despite the neuromuscular disease. Residual effect of the neuromuscular blocking agent was successfully reversed by sugammadex and she was extubated without any respiratory trouble. She was discharged on the postoperative day 1 without complications.

A 60-year-old woman visited our hospital due to hematochezia. Colonoscopy revealed a 50-mm-diameter submucosal tumor with ulceration of the left side of the transverse colon, and magnetic resonance imaging (MRI) demonstrated the presence of small hepatic nodules. Submucosal tumor of the colon with liver metastasis was therefore diagnosed. To prevent tumor bleeding, we performed partial transverse colectomy. The histopathological diagnosis was moderately differentiated hepatocellular carcinoma presenting as a submucosal tumor with a high frequency of vascular invasion. Computed tomography (CT) angiography revealed a 40-mm-diameter confluent multinodular-type hepatocellular carcinoma with outward spread from segment II and multiple intrahepatic metastases. Our final diagnosis was hepatocellular carcinoma with hematogenous colon metastasis.

At present, the development of the accelerator-based irradiation system for boron neutron capture therapy (BNCT) is energetically performed by various groups in the world. Especially in Japan, BNCT using various accelerator-based irradiation systems may be carried out at plural facilities in the near future. Thus, it is the time when BNCT is shifting from a special particle therapy to a general therapy, now. In order to promote this shift, not only the development and improvement for the irradiation system but also the preparation and improvement in the physical engineering and medical physics, such as dosimetry system, etc., is important. Recently, as part of the improvement in the dosimetry method for BNCT, the estimation method of three-dimensional dose distribution using gel detector is focused. In this paper, the principle of BNCT, especially for dose deposition, is introduced, and the studies for gel detector in BNCT are introduced referring to the proceedings of the international symposium for BNCT.

It is known that a portion of an epidural catheter can remain embedded when the catheter is pulled back at the time of insertion or a longer length than required is used. We report a case in which an epi- dural catheter piece including a metal coil broke off and remained embedded at the time of withdrawal. Because of the presence of the coil, MRI could not be utilized, while CT scanning was useful to locate the remaining portion. Following surgical extraction, the embedded portion was thoroughly examined. The point of the catheter was cut sharply, which suggested that damage occurred without awareness of the anesthesi- ologist When a catheter breaks leaving a remnant surgical extraction should be considered based on appropriate examination findings.

Pediatric advanced life support (PALS) is the global standard of pediatric emergency medicine. It depends on the consensus of ILCOR which has been revised every 5 years by the experts worldwide. The concept of PALS is to treat the sick and injured children based on the systematic approach of the evaluation and classification in terms of the respiratory and circulatory status. On the other hand, point of care ultrasound (POCU) has been getting popular worldwide in the field of the emergency and critical care medicine. The PALS approach mainly depends on the physical examination which isn't enough for the decision making of the treatment. Then, POCU has come out as the adjunctive methods to compensate for the physical examination. This article outlines the concept of PALS and POCU.

The principle and clinical application of measurement of cerebral blood perfusion (CBP) using MRI are described. Purposes of measuring CBP using MRI are wide-ranging. Generally, it is used to diagnose cerebro-vascular disorders or brain tumors. There are two types of measuring methods. One is dynamic susceptibility contrast (DSC) method using a contrast agent as a tracer. Another is an arterial spin labeling (ASL) method using protons in arterial blood as an endogenous tracer, instead of bio-exogenous tracer. Basic theory of ASL method was published in the 1990s, recently, its clinical application has been spreading rapidly by the technological innovations. ASL method is attractive as a way to measure CBP because of its non-invasiveness (no radiation-exposure, not need intravenous injection or blood sampling), and the imaging time is about 5 minutes, thereby the measurement can be repeated. The analysis of DSC method has not been standardized, though various valuable parameters are provided. And the prerequisite of DSC method is uncertain in vivo. On the other hand, the result of ASL is affected by the post labeling delay, and limited to the arterial information.

Ebola virus is an enveloped virus with filamentous structure and causes a severe hemorrhagic fever in human and nonhuman primates. Host cell entry is the first essential step in the viral life cycle, which has been extensively studied as one of the therapeutic targets. A virus factor of cell entry is a surface glycoprotein (GP), which is an only essential viral protein in the step, as well as the unique particle structure. The virus also interacts with a lot of host factors to successfully enter host cells. Ebola virus at first binds to cell surface proteins and internalizes into cells, followed by trafficking through endosomal vesicles to intracellular acidic compartments. There, host proteases process GPs, which can interact with an intracellular receptor. Then, under an appropriate circumstance, viral and endosomal membranes are fused, which is enhanced by major structural changes of GPs, to complete host cell entry. Recently the basic research of Ebola virus infection mechanism has markedly progressed, largely contributed by identification of host factors and detailed structural analyses of GPs. This article highlights the mechanism of Ebola virus host cell entry, including recent findings.

Norman Geschwind was an outstanding American neurologist. He first majored in psychology and then medicine at Harvard University. After graduation, he received neurological training at Beth Israel Hospital, the National Hospital at Queen Square in London, and Boston City Hospital, under the guidance of Denny-Brown, Charles Symonds, and Fred Quadfasel. He later moved to the Boston Veterans Administration Hospital, and established the Boston University Aphasia Research Center with Edith Kaplan. This center played a cardinal role in aphasia research in the United States. In 1969, Geschwind became a Professor at Harvard Medical School. Disconnection syndromes, which made Geschwind's name famous worldwide in the field of neurology, are reviewed here in regard to pure alexia, conduction aphasia, pure word deafness, isolation of the speech area, and apraxia, with reference to the Wernicke-Geschwind model. Other contributions by Geschwind are also described, such as behavioral changes in temporal lobe epilepsy (Geschwind syndrome) and cerebral lateralization, including the Geschwind-Galaburda hypothesis.

Background: The aim of this observational study is to examine the benefit of ultrasound assessment of gastric content in cesarean delivery (CD) patients., Methods: Thirty-nine patients scheduled for CD were assigned to a scheduled CD group and to an emergency group. Before CD, gastric ultrasonography examinations to calculate CSA (cross sectional area) of gastric antrum were performed to determine if gastric content was residual, and patients in the emergency group were asked what and when they had eaten. They were classified as full stomach when CSA was 2.5 cm2 or more and the sonographic characteristics of the antrum showed mixture with high echogenic particles., Results: Eight patients were assigned to a scheduled CD group and thirty-one patients to an emergency group, respectively. None of the scheduled CD group should be CSA of 2.5 cm2 or more and eight of the emergency group should be 2.5 cm2 or more, including 3 patients with or without labor showing residual gastric contents after more than 10 hours of ingestion., Conclusions: There are some CD patients with the high risk of aspiration with or without labor even 10 hours after the last ingestion.

The survival rate of cardiac rupture due to blunt trauma is generally low. We experienced a case with right ventricular rupture due to blunt trauma. The patient was a 49-year-old man who was crushed in a traffic accident and transported to a local hospital in a shock state. He was diagnosed with cardiac tamponade due to cardiac rupture, and for pericardial drainage was immediately performed. He was then transferred to our hospital for emergency surgery. His hemodynamics was stable, and he was diagnosed with right ventricular rupture by multi-detector row computed tomography (MDCT). The operation was performed successfully without cardiopulmonary bypass, and his postoperative course was uneventful. MDCT is useful for detecting the rupture site of the heart.

The patient was a 69-year-old male who had had percutaneous transvenous mitral commissurotomy (PTMC) 15 years ago, and had stopped taking warfarin after PTMC. He was transferred to our emergency room( ER) because of sudden severe pain in his both lower legs. We recognized pulselessness in his both femoral arteries, and pallor, paresthesia and poikilothermia in his lower extremities. Electorocardiogram(ECG) showed arterial fibrillation, and computed tomography( CT) showed occlusion of the abdominal aorta just below inferior mesenteric artery( IMA) and both common iliac arteries. By echocardiography, a giant thrombus was detected in the left atrium with severe mitral stenosis. Thrombectomy and angioplasty were performed at about 5 hours after the onset of occlusion, and revascularization was successful. Three days after the operation, we excised the giant thrombus in the left atrium and performed mitral valve replacement because we considered that myonephropathic metabolic syndrome (MNMS) had been prevented. The postoperative course was uneventful and he was discharged on the 27th postoperative day.

Background: To test safety and efficacy of ORT (oral rehydration therapy), we compared an ORT group with an intravenous infusion (i.v.) group by gastric fluid (volume and pH) obtained by endoscope and gastric ultrasonography examination., Methods: Twenty six patients scheduled for endoscopic surgery were assigned to an ORT group or an i.v. group by standardized clinical path. After gastric ultrasonography examinations to calculate CSA (cross sectional area) of gastric antrum, general anesthesia was induced. Immediately after anesthesia induction, gastric fluid was obtained by endoscopy, and its volume and pH were measured., Results: Fifteen and eleven patients were assigned to ORT group and iv group, respectively. In ORT group, CSA was median 1.9 cm2 (95% CI:1.8-2.6 cm2), gastric volume was median 11 ml (95% CI: 8-18 ml) and pH was median 3.6 (range: 1.2-8.8), and in i.v. group CSA was median 1.8 cm2 (95% CI: 1.6-2.7 cm2), gastric volume was median 4 ml (95% CI: 3-12 ml), and pH was median 3.1 (range: 1.2-7.2). There was no significance between the two groups., Conclusions: Gastric volume in ORS group was not smaller compared with that in i.v. group, and there was no significant difference in pH between the groups.

Background: We investigated whether sugammadex could reverse neuromuscular blockade induced by rocuronium in patients for cesarean delivery treated with magnesium sulfate preoperatively., Methods: Twenty-three pregnant women received general anesthesia induced with thiopental and rocuronium. They were maintained by nitrous oxide, oxygen and sevoflurane (GOS) before delivery and after delivery by GOS, midazolam, and propofol. After the surgery, the patients with two or more counts of train-of-four (TOF), the moderate block group were classified into Mg (-) M and Mg (+) M, depending whether magnesium sulfate had been injected or not, and sugammadex 2 mg x kg(-1) was administered to both groups. Patients with PTC 2 or more, the profound block group, were classified into Mg (-) P or Mg (+) P and sugammadex 4 mg x kg(-1) was administered to both groups. Recovery time was defined as the time required to reach TOFR 0.9 or more after the injection of sugammadex., Results: Median recovery times of the Mg (-) M, the Mg (-) P, the Mg (+) M and the Mg (+) P were 63 seconds (range: 26-130, N = 7), 127 seconds (range: 63-228, N = 7), 104 seconds (range: 67-133, N = 5), and 142 seconds (range: 57-209, N = 4), respectively., Conclusions: Sugammadex could reverse rocuronium-induced neuromuscular blockade in a dose-response manner even in the patients treated with magnesium sulfate.

Background: Although magnesium can potentially shorten onset time of a muscle relaxant, it is unclear whether it does shorten the onset time of rocuronium for patients in cesarean delivery (CD). Thus the purpose of this study is to compare the onset time of rocuronium in patients with or without preoperative magnesium treatment., Methods: In 9 CD patients without magnesium (CD group) and 8 CD patients with magnesium (CD-Mg group), neuromuscular function was continuously assessed with acceleromyography immediately after induction of general anesthesia with intravenous injection of thiopental (4-5 mg x kg(-1)) and rocuronium (0.6 mg x kg(-1)). Onset time of muscle relaxation, defined by the time from rocuronium bolus injection until complete absence of twitch height, was measured., Results: The onset time of both groups did not significantly differ (50 +/- 10 seconds vs. 51 +/- 11 seconds; P = 0.93, unpaired t-test). Median magnesium concentration, 5.2 mg x dl(-1) (3.8-6.3), and the onset time of CD-Mg group did not correlate magnesium concentrations (P = 0.23, Pearson's correlation coefficient test)., Conclusions: Magnesium did not shorten the onset time of rocuronium 0.6 mg x kg(-1) in CD patients.

Background: Rapid onset of a muscle relaxant is required for general anesthesia with rapid sequence induction technique. Although a high dose of rocuronium was demonstrated to achieve the rapid onset in non-pregnant persons, it is still unknown whether this is true in women during late pregnancy. The purpose of this study is to compare the onset time of high dose rocuronium between pregnant and non-pregnant women., Methods: Ten pregnant women undergoing cesarean delivery and 10 age, height, and body weight-matched non-pregnant women were enrolled in the study. Neuromuscular function was continuously assessed by twitch response with acceleromyography immediately after induction of general anesthesia with intravenous injection of thiopental (4-5 mg x kg(-1)) and rocuronium (0.9 mg x kg(-1)). Onset time of muscle relaxation, defined by the time from rocuronium bolus injection to complete absence of twitch height, was measured., Results: The onset time of rocuronium in pregnant women was significantly shorter than that in non-pregnant women (42 +/- 9 seconds vs. 56 +/- 10 seconds; P = 0.0039. unpaired t-test)., Conclusions: The onset time of high dose of rocuronium in pregnant women was significantly shorter than that of non-pregnant women.

Various custom-made phantoms designed to optimize magnetic resonance imaging (MRI) sequences have been created and subsequently reported in JSRT. However, custom-made phantoms that correctly match the T1-value and T2-values of human brain tissue (gray matter and white matter) cannot be made easily or quickly. The aim of this project was to search for alternative materials, such as fruits and vegetables, for optimizing MRI sequences. The following eight fruits and vegetables were investigated: apple, tomato, melon, apple mango (Mangifera indica), banana, avocado, peach, and eggplant. Their potential was studied for use in modeling phantoms of normal human brain tissues. MRI (T1- and T2-weighted sequences) was performed on the human brain and the fruits and vegetables using various concentrations of contrast medium (gadolinium) in the same size tubes as the custom-made phantom. The authors compared the signal intensity (SI) in human brain tissue (gray matter and white matter) with that of the fruits and the custom-made phantom. The T1 and T2 values were measured for banana tissue and compared with those for human brain tissue in the literature. Our results indicated that banana tissue is similar to human brain tissue (both gray matter and white matter). Banana tissue can thus be employed as an alternative phantom for the human brain for the purpose of MRI.

The objective of our study was to optimize magnetic resonance image (MRI) sequences and parameters using operative assisted images (three-dimensional images) for radical prostatectomy at 3 tesla (T) MRI. Five healthy volunteers underwent MRI on the 3.0 T scanner. Various sequences and parameters [Cube (TE/TR = 18, 50, 90 ms/2000 ms), FIESTA (TE/TR/FA = 2.4 ms/5 ms/40 degrees, 90 degrees), fSPGR (TE/TR/FA = 2.3 ms/11.2 ms/20 degrees), slice thickness = 1.2 mm, matrix = 192 x 160] were respectively compared. Several structures of the pelvis (the central zones and transition zones of the prostate, the peripheral zones of the prostate, seminal vesicles, rectum wall, bladder, muscle and fat) were determined. The signal intensities of these structures were measured on reformatted axial images and compared against several structures of the pelvis. Correlation with various sequences and parameters was based on the signal-to-noise ratio (SNR), the contrast ratio (CR) and the presence of artifacts. Student's t-test was used for statistical analysis. With Cube (TE/TR = 50 ms/2000 ms), the average value of visual evaluation with artifacts was high, and SNR and CR were higher than for other sequence and parameters. Optimized MRI sequences and parameters were Cube (TE/TR = 50 ms/2000 ms) which provides improved SNR and CR and the presence of artifacts with operative assisted images for radical prostatectomy. These operative assisted images obtained from Cube (TE/TR = 50 ms/2000 ms) are likely to be useful for surgery.

Background: It has been demonstrated that preparatory ultrasound scanning can facilitate lumbar epidural anesthesia. We compared longitudinal with transverse approach of ultrasound imaging to test the precision and the quality of acquired images in cesar ean delivery patients., Methods: We enrolled 34 cesarean delivery patients. Measured distances from the skin to dura on each ultrasound view was compared with the actual needle depth. Additionally we measured ultrasound visibility score., Results: The both distances measured in ultrasound strongly correlated with the actual depth (R2= 0.87 and 95% limits of agreement of -3.07 to 6.45 mm on longitudinal view, R2=0.82 and 95% limits of agreement of -3.50 to 7.74 mm on longitudinal view). The visibility score of the longitudinal view was significantly higher than that of transverse view (P<0.01)., Conclusions: Both planes provided accurate information about the epidural space and depth, and the longitudinal plane was superior in the imaging quality. It was suggested that both approaches may help identify epidural spaces.

Chronic expanding hematoma(CEH)was first recognized by Reid in 1980. It begins to expand chronically more than 1 month after surgery or trauma, which is considered the possible cause of bleeding. It resembles chronic subdural hematoma. Most of the reports on CEH are those in the thoracic cavity or muscles, and few are in the pericardial cavity after open heart surgery. Our case was a 64-year-old male, who had undergone coronary artery bypass grafting (CABG) 18 years before. He presented with symptoms of heart failure such as exertional dyspnea, general fatigue and appetite loss. Computed tomography( CT) scan showed severe compression of the left ventricle by a large mass, and he was diagnosed with intrapericardial CEH. Resection of the severely calcified epicardium as well as removal of the hematoma in the pericardial cavity was performed, and the symptoms of heart failure improved. No recurrence has been noted for 1 year since the operation. A long-term follow-up will be necessary.

A 32-year-old pregnant woman diagnosed with aplastic anemia was admitted for emergent caesarean delivery of 26th week of the gestation due to PIH (pregnancy-induced hypertension) and NRFS (non-reassuring fetal status). After compensating platelets counts to 5.3x10(4) microl-1, general anesthesia was induced with propofol and rocuronium. Anesthesia was maintained with O2 and sevoflurane until delivery and with modified-NLA after delivery. She was additionally monitored with Vigileo/FloTrac system (Edwards Lifesciences, USA) and TOF-WATCH SX (Nihon Kohden, Tokyo). After 8 minutes of operation her baby was born with the 5-minute Apgar score of 5 and the UA-pH of 7.387. It was only 2 hours and 12 minutes that the baby was born after she was admitted. The baby was tracheally intubated and transferred to NICU. Blood loss during operation was 835 g and two units of RCC was transfused. Circulatory values were kept acceptable and neuromuscular blocking was completely reversed by sugammadex and extubated in the operating room. Bleeding tendency and atonic bleeding were not observed. She survived perioperative period and was to be treated for aplastic anemia. Her baby was discharged neurologically free. We should be ready to respond to anesthetic requirement for urgent cases of aplastic anemia.

The author reviews the lesion localization of non-aphasic alexia and agraphia and proposes a new classification of alexia and agraphia on this basis. The newly proposed alexia and agraphia are pure alexia for kana (Japanese phonograms), or more generally pure alexia for letters, caused by a lesion in the posterior occipital area (posterior fusiform/inferior occipital gyri), and pure agraphia for kanji (Japanese morphograms) caused by a lesion in the posterior middle temporal gyrus and also a lesion restricted to the angular gyrus. In addition, the anatomical lesions presumably responsible for the parietal apraxic agraphia, frontal pure agraphia and thalamic agraphia are discussed.

Many anesthesiologists are reluctant to depart from their traditional long fasting periods, even though many guidelines recommend that oral intake of clear fluids administered up to 2-3 hours prior to general anesthesia does not adversely affect the gastric contents. It also indicates that the application of these guidelines does not affect the incidence of pulmonary aspiration. One of the reasons why they have not changed their practices is that they wonder whether it is safe to administer clear fluids as recommended in the guidelines. In this review, we emphasize that oral rehydration therapy using clear fluids (such as OS-1, water and carbohydrate-rich beverage) is safe based on the non-invasive gastric echo examinations as many guidelines have already indicated. Oral rehydration therapy should be considered not only as an alternative to intravenous therapy for preoperative fluid and electrolyte management but also as one of the important modalities which can enhance the recovery of surgical patients.

Background: OS-1 is an oral rehydration solution that conforms with the principles of oral rehydration therapy. It may be useful for preoperative fluid management of surgical patients. While intake of clear fluids 2 hours before surgery is considered safe, it is not known if the same applies to OS-1. We therefore investigated the safety of OS-1 for preoperative patients as compared with clear fluids., Methods: First, eight healthy adult volunteers were studied in a crossover manner. Volunteers ingested 500 ml of OS-1 or water (clear fluid). Gastric emptying time was measured using gastric ultrasonography. Gastric antral area as measured by ultrasonography correlates well with gastric volume in a close-to-linear manner. Next, we measured gastric volume of elective surgical patients who had drunk OS-1 until two hours before the induction of anesthesia., Results: Gastric emptying time did not differ between OS-1 and water. The stomach was emptied 30 minutes after ingestion of both OS-1 and water. The fasting stomach was identified in all patients who had drunk OS-1 before surgery., Conclusions: We concluded that allowing elective surgical patients to drink OS-1 until two hours before anesthesia did not affect the volume of gastric contents.

Although neoadjuvant chemotherapy has been recognized as an important option to improve the clinical outcome of patients with advanced gastric carcinoma, the precise histological effects of neoadjuvant chemotherapy on the primary and metastatic foci have not well been documented. The aim of the present study was thus to evaluate histological effects of S-1-based neoadjuvant chemotherapy on the resected specimens of gastric carcinoma and regional lymph nodes, and primarily to focus on the histology of the cases showing complete regression of the primary cancer cells. A total of 164 patients received neoadjuvant chemotherapy with the combination of S-1 (80 to 120 mg/body/day for 3 weeks) and cisplatin (35 to 60 mg/m2 on day 8). One course of the regimen was completed in 5 weeks and the next course was started after 2 weeks. A total of 9 patients who showed complete regression of the primary gastric cancer were subjects of the study. A total of 77 cases (46.9%) responded to the neoadjuvant chemotherapy and 9 cases (5.5%) showed a complete regression of the primary gastric carcinoma. Three out of 9 cases had remnant cancer cells in the metastatic foci; 1 in the liver and 2 in the regional lymph nodes. Five of 9 cases were solid-type poorly-differentiated adenocarcinoma (por1), and the incidence of responders was the highest in patients with por1. A total of 8 cases were alive and the mean postoperative survival was 612±192 days. One patient died 518 days after gastrectomy associated with hepatic resection. S-1-based neoadjuvant chemotherapy has significant histological effects on gastric carcinoma and metastatic foci, which may further improve long-term clinical outcome in patients with advanced gastric carcinoma.

Brain-machine interfaces (BMIs) are artificial systems that control external devices or body muscles with signals generated by the neural activities of working brains. The BMIs currently under development can be divided into 2 types,i.e.,conventional (noninvasive) BMIs and complete (invasive) BMIs. Only the latter type of BMI can ultimately be used in the future. This paper describes some recent studies on invasive BMI using monkeys as subjects and discusses the progress of and problems revealed in these studies. The focus then shifts to plastic changes in neuronal activities caused by the BMIs. When a BMI is in use,the brain inevitably changes its own functions and structures in order to operate external devices more efficiently. Therefore,basic research on BMIs inevitably involves study on neural plasticity; such research is essential for further development of neurorehabilitation and for high performance of BMIs. This paper describes 2 recent pioneering BMI studies-one involving the rat motor cortex and the other involving the monkey primary motor cortex. Both studies revealed rapid and plastic changes in neuronal function during the period the animals were learning to operate external devices with the BMIs. The fact that the neuronal changes were caused by the contingency of neuronal activity and rewards emphasizes the significance of the neural-operant paradigm for research on neuronal plasticity in BMIs. The present paper describes a neural-operant experiment involving a recently developed high-performance BMI system and reports rapid and plastic changes in firing frequency and synchrony of the hippocampal neurons in both adult and aged rats. Finally,the paper suggests that complete BMIs can be developed by neuroscience research and should be able to unmask the enigmas of the neural code,brain-body interaction,and ongoing activity in the working brain.

A 66-year-old woman presented to our outpatient clinic with abdominal discomfort in April, 2008. Ultrasound revealed a hypo-echoic 10cm mass in the right hepatic lobe but no indication of chronic liver disease, with similar results in her history, on physical exam, and imaging. Serum testing did not identify any systemic disease. The mass was suspected to be intrahepatic cholangiocarcinoma and right hepatic lobectomy was performed. Histologic examination of the specimen revealed numerous spindle cells, and immunostaining confirmed a definitive diagnosis of sarcomatoid carcinoma of the liver. On subsequent review of the case, an abdominal CT performed 2.5 years earlier for unrelated symptoms had shown a 1cm faint low density area in the same location as the mass. The doubling time of this tumor was about 95 days.

Polypregnancy is one of the major problems to both mothers and fetuses leading to poor prognosis. Even though hemodynamic parameters change greatly during pregnancy and cesarean delivery, it is unclear how blood volume (BV) and cardiac output (CO) increase during triplet pregnancy and how CO goes up and down during cesarean delivery in the cases of triplet pregnancy. We measured BV and CO by dye-densitogram analyzer (DDG-analyzer: Nihon Kohden, Tokyo, Japan) and CO by FlowTrac (Edwards Lifesciences, Irvine, USA) on three cases of triplet pregnancy. BV increased up to about 50% above that of singleton after 20 weeks of gestational age. However, there was no such tendency in CO. When they underwent cesarean delivery under combined spinal-epidural anesthesia (CSEA) or sequential-CSE (S-CSE) receiving a 10 or 12 mg intrathecal isobaric bupivacaine with 20 microg fentanyl, CO decreased in parallel with blood pressure from ten minutes after spinal anesthesia, to the start of operation and just after the birth of third fetus.

The advent of thoracoscopic esophagectomy (TSE) has enabled early patient recovery in association with changes in perioperative nutritional support. This article reviews recent changes in the perioperative nutritional support for patients undergoing TSE. TSE associated with a laparoscopic procedure facilitates the recovery of gastrointestinal motility and function while decreasing the incidence of vocal cord paralysis and/or difficulties in swallowing due to accurate mediastinal lymph node dissection. Thus, recent trends in perioperative nutritional support have been early oral feeding and perioperative enteral feeding using a disease-specific polymeric immunoenhancing or immunomodulating enteral formula. Although TSE is associated with less surgical invasiveness, nutritional support still plays an important role in perioperative care to prevent postoperative complications and contribute to the early recovery of nutritional status. Moreover, since TSE is now performed to treat advanced esophageal cancer, patients are frequently malnourished preoperatively and therefore in the group at high risk for postoperative complications. The early start of oral feeding after the evaluation of swallowing function, selecting the appropriate route for enteral nutrition, and sufficient calorie intake during the perioperative period are essential to prevent postoperative pulmonary and/or infectious complications and consequently to improve patient quality of life.

Background: Although obstetric disease is one of the major causes of disseminated intravascular coagulation (DIC), no gold standard exists. Three current criteria, the Japanese Association for Acute Medicine (JAAM) -DIC criteria, the revised Japanese Ministry of Health and Welfare (JMHW) criteria and the International Society on Thrombosis and Haemostasis (ISTH) criteria, do not clarify the usefulness in obstetric DIC. We therefore conducted a retrospective study by simulation., Methods: We enrolled 89 cases of emergent caesarean section when platelet count decreased to below 150,000 x 10(9) x mm(-3) during 7 days from 3 days before operation to 3 days after operation from April 2004 to March 2007. We applied them and compared diagnostic rates and investigated characteristics of obstetric DIC., Results: After excluding 21 cases, 68 cases were examined. The number of patients diagnosed with DIC by JAAM-DIC criteria, JMHW criteria and ISTH criteria were 15 (22.1%), 5 (7.4%) and 3 (4.4%), respectively. Fifteen patients who fulfilled JAAM-DIC criteria included all 5 patients for whom DIC was diagnosed by JMHW criteria, and those 5 patients included all 3 patients for whom DIC was diagnosed by ISTH criteria., Conclusions: The current study indicates that JAAM-DIC criteria can be useful but may overdiagnose the DIC.