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Simultaneous administration of enteral formula and phenytoin in the clinical setting is known to reduce the plasma concentration of phenytoin. In this study, we examined the binding of phenytoin with enteral formulas and its components by quantifying the free phenytoin concentration. Furthermore, we investigated the effect of enteral formulas on gastrointestinal absorption of phenytoin in rats. The free phenytoin rate was reduced in vitro when phenytoin and enteral formula or pectin, a dietary fiber in enteral formulas, were co-administered. In vivo, when phenytoin and the enteral formula Mei Balance R ® were co-administered, the time to maximum plasma concentration (T max ) after oral administration was significantly increased. Moreover, the area under the phenytoin concentration-time curve from time zero to 6 h (AUC 0-6 h ) was significantly increased by co-administration of phenytoin with the enteral formula PG Soft EJ ® . These results showed the gastrointestinal absorption of phenytoin differs according to the type of enteral formula. In addition, we found the first time that plasma phenytoin levels increase when combined with enteral formula. Among the components of enteral formulas, in particular, milk protein delayed the absorption of phenytoin. Moreover, milk protein, casein and carrageenan tended to increase AUC 0-6 h . These results suggest the change in phenytoin concentration is due not only to the binding of enteral formula but also to the disintegration of components such as protein. Therefore, when co-administrated of phenytoin and enteral formula, phenytoin must be monitored frequently according to the enteral formula interaction.

A 69-year-old woman underwent extended cholecystectomy for gallbladder cancer[T2N0M0, fStage Ⅱ(UICC 7th edition)]. She was then administered adjuvant S-1 and was treated for drug-induced neutropenia. One year later, recurrent lesions were detected in liver S4 and S5. We treated the patient with hepatectomy and hepatic arterial infusion adjuvant chemotherapy by cisplatin, along with the systemic administration of gemcitabine for 10 months. The patient is now doing well without any sign of recurrence 29 months after the initial operation and 16 months after the secondary liver resection.

A 53-year-old man was admitted to our hospital with the complaint of neck pain and dyspnea. His blood examination revealed increased C-reactive protein and amylase levels. Enhanced computed tomography (CT) images demonstrated a retropharyngeal and a mediastinal low-density area extending to the portal area. He was diagnosed with pancreatic pseudocyst from the abdominal cavity to the cervical region accompanied by spontaneous rupture into the portal vein. Endoscopic ultrasound-guided cyst drainage (EUS-CD) of the most inferior cavity around the superior mesenteric artery was performed through the gastric wall. No adverse events were recorded during the procedure, and a near-complete resolution of his symptoms and the pseudocyst was achieved.

We report a case of subarachnoid hemorrhage(SAH)with multiple cerebral aneurysms, in which magnetic resonance vessel wall imaging(MR-VWI)revealed the rupture site. A 68-year-old woman presented with SAH. Computed tomography(CT)showed diffuse SAH(Fisher group 3). 3D-CT angiography revealed two intracranial aneurysms:a 4.2-mm anterior communicating artery aneurysm(Acom An)and a 5.8-mm basilar tip aneurysm(BAtip An). As the BAtip An was the larger of the two, it was deemed the most likely site of rupture;however, high-resolution MR-VWI with gadolinium showed thick wall enhancement in the Acom An and no enhancement in the BAtip An. Thus, we performed a craniotomy for the Acom An. Intraoperative findings confirmed the rupture site at the Acom An. We concluded that high resolution MR-VWI may be useful for identifying the rupture site in patients with spontaneous SAH and multiple cerebral aneurysms.

A 70-year-old woman was diagnosed as having advanced lower thoracic esophageal cancer with abdominal lymph node metastases(T3N1M0, Stage III). After administering 2 courses of neoadjuvant chemotherapy with 5-fluorouracil(5- FU)( 800 mg/m2)and cisplatin(80 mg/m2), we performed curative surgery with D2 lymph node dissection. The patient could not receive adjuvant chemotherapy because of her poor performance status. After curative surgery, liver metastasis appeared in segment 8. The liver metastasis(S8)was treated with stereotactic body radiation therapy(SBRT)( 60 Gy/3 Fr). After SBRT, we administered systemic chemotherapy with docetaxel and nedaplatin as second-line chemotherapy. The patient had no recurrence for 12 months after SBRT. SBRT exhibited an excellent local therapeutic effect without any serious complications, suggesting that it is an effective treatment for liver metastasis from esophageal cancer.

Glucocorticoids were widely used for the treatment of various disorders. Therefore, the management of glucocorticoid-induced osteoporosis (GIOP) is referred to doctors who take care of underlying diseases. Since glucocorticoid-induced bone loss is most rapid during the initial 3-6 months, primary prevention of bone loss is especially important.The Japanese Society of Bone and Mineral Metabolism have devised a guideline for the management of GCOP and bisphosphonates play a central role for the primary and secondary prevention of GIOP. Human PTH (1-34) , teriparatide is possible another beneficial drug in addition to bisphosphonates.

Recently a number of therapies have been reported on the treatment efficacy for glucocorticoid-induced osteoporosis (GIOP) . Especially, bisphosphonates have been proven to have both prevention and treatment of GIOP by large-scale randomized double-blinded placebo controlled studies and recommended the use of them as a first line therapy by treatment guideline in many countries. On the other hand, activated vitamin D(3) analogues also have been reported the effectiveness of GIOP although the effect is lower than bisphosphonates. Vitamin K(2) analogues suggested to have the efficacy in treatment of GIOP in Japan. This article reviews the evidence of treatment efficacy of current treatment especially bisphosphonates in patients with GIOP.

A 30-year old man was admitted to our hospital with cough, slight fever, and dyspnea that he had developed several hours after inhaling the fumes produced from a Teflon-coated pan, after evaporation of the water in the pan. Chest radiography revealed diffuse infiltrations, and a computed tomography (CT) scan revealed patchy interstitial shadows in both lungs. In pulmonary function tests, the diffusing capacity of the lungs showed a moderate decrease. Leukocytosis and slight hypoxemia were observed. The patient recovered clinically in a few days without any specific treatment. We speculated that the pulmonary problems in this patient may have been induced by the products of thermal degradation of Teflon that were present in the fumes. When Teflon is heated, the fumes generated cause an influenza like syndrome (polymer fume fever) or cause severe toxic effects such as pulmonary edema, pneumonitis, and death in the exposed individual.

Polymyositis/Dermatomyositis (PM/DM) is a chronic inflammatory disorder that culminates in injury to the skin and muscle and, sometimes, is accompanied by interstitial lung disease (ILD). A number of autoantibodies are associated with myositis, including those specific for aminoacyl-tRNA synthetase (anti-ARS), signal recognition particle (anti-SRP), and Mi-2. These autoantibodies have proven to be useful in the diagnosis and classification of the diseases and are predictive of prognosis. It has been known that certain patients may have typical DM skin manifestations without clinical evidence of myositis for at least 2 years (Clinically Amyopathic DM; C-ADM). Although classical myositis-related antibodies are well known, specificities related to C-ADM have not been examined in detail. Therefore, we have examined sera from 15 Japanese patients with C-ADM to identify additional autoantibodies associated with this disease. Eight sera of C-ADM patient recognized a polypeptide of approximately 140 kDa and we named this new antibody specificity anti-CADM-140. Anti-CADM-140 antibodies were detected in 8 of 42 patients with DM, but not in patients with other connective tissue diseases or idiopathic pulmonary fibrosis. It is noteworthy that DM patients with anti-CADM-140 had significantly more rapidly progressive ILD when compared to patients without anti-CADM-140 (50% vs 6%, P=0.008). Further studies of the pathogenicity of these autoantibodies specificity may provide insight into the pathogenic mechanisms of PM/DM accompanied by rapidly progressive ILD.

We examined the clinical characteristics of post stroke depression (PSD) patients in a rehabilitation hospital. The subjects were inpatients at the Ibaraki Prefectural University of Health Sciences Hospital who had been diagnosed with stroke and admitted between May 2002 and January 2004. Of 123 patients enrolled, 18 were diagnosed with PSD. We investigated the clinical differences between PSD patients and non-depressed (ND) patients. There were no significant differences between PSD and ND groups in terms of sex, age, past psychiatric history, family psychiatric history, stroke diagnosis, or neurological symptoms. The scores of PSD patients on Zung's self-rating depression scale and the Hamilton depression rating scale were significantly higher than those of ND patients. Furthermore, the Activities of Daily Living measured by the Functional Independence Measure and cognitive function evaluated by the Mini-Mental State Examination of ND patients were significantly better than those of PSD subjects. These results suggest that the detection of PSD in stroke patients is important for promoting their rehabilitation and improving their Activities of Daily Living and cognitive function.

A 52 year-old woman noticed general fatigue, polyarthralgia, and muscle weakness of lower extremities in October 2001. In December, she felt difficulty in walking due to muscle weakness. In January 2002, she admitted another hospital because of dyspnea on exertion and edema of lower extremities. Laboratory test revealed leukocytopenia, the elevation of creatine kinase and positive anti-U1-RNP antibodies. Her chest computed tomography (CT) showed severe interstitial pneumonia. Cardiac echogram revealed that she had pericardial effusion and pulmonary hypertension. Then she was transferred to Keio University Hospital and she was diagnosed as having mixed connective tissue disease (MCTD) manifestating myositis, interstitial pneumonia, pulmonary hypertension and pericarditis. Prednisolone (PSL) 60mg daily following to methylprednisolone (mPSL) pulse therapy was begun and her symptoms were gradually improved. In middle of February, she complained of high fever over 39.0 degrees C. Bacterial culture tests were negative and laboratory data indicated pancytopenia and a high level of serum ferritin. Bone marrow aspiration revealed hemophagocytosis in bone marrow specimens and she was diagnosed as having hemophagocytic syndrome associated with MCTD. mPSL pulse therapy was not effective and intermittent cyclophosphamide pulse therapy (IV-CY) was performed resulting in improvement of the symptoms. This case suggested the effectiveness of IV-CY therapy in patients with corticosteroid-resistant HPS associated with connective tissue diseases.

An advantage of heavy-ion therapy is its good dose concentration. A limit for full use of this desirable feature comes from range ambiguities in treatment planning. The treatment planning is based on X-ray CT measurements, and the range ambiguities are mainly due to an error in calibration of the CT number. The heavy-ion ranges are related to electron density of the medium while the CT numbers are defined using the X-ray attenuation coefficient. The range verification method using positron emitter beams has been developed to reduce the range ambiguities. In this verification, probing beams of positron emitters are implanted into the tumor, and pairs of annihilation gamma rays are detected with a positron camera. This paper demonstrates an application to verify treatment planning. Here the treatment planning was made on a head phantom and the ranges estimated from the CT-number were compared with the ranges measured with the positron camera. As a result, disagreements were detected between the planned ranges and the measured ones; there were 1.6 mm at maximum. The disagreements were due to an error of transformation of CT-number to range for the phantom material in the water column depth-dose measurement. The disagreements could be lowered to 0.4 mm by using the calibrated water-equivalent lengths. It was confirmed that the range verification system has a designed measurement accuracy of 1 mm and is useful for verifying irradiation fields on heavy-ion radiotherapy.

A 53-year-old male was anesthetized for left upper lobectomy under one-lung ventilation using a double-lumen endobronchial tube in the lateral position. When the upper left pulmonary vein was ligated, Pao2/FIo2 ratio (PF ratio) was elevated despite the one-lung ventilation. After the operation, the patient was repositioned onto spine position and massive bleeding occurred from the anomalous lower left pulmonary vein, which was ligated during the operation. The lower left pulmonary vein was restored and the bleeding stopped. Because the pulmonary shunt flow from the lower left pulmonary vein had stopped, the PF ratio was unusually elevated. We urge anesthesiologists to pay attention to the arterial blood gas data even when it is better than expected.