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[Purpose] In this study, we aimed to investigate the improvement in muscle blood flow due to acupuncture based on changes in the oxygen hemodynamics and muscle temperature. We also compared the effects of electroacupuncture with those of other therapies that are similar to other acupuncture. [Methods] The study population consisted of male college volleyball players. The subjects are divided into 4 groups: the electroacupuncture (EA) group: 30 subjects; acupuncture (ACU) group: 30 subjects; transcutaneous electrical nerve stimulation (TENS) group: 30 subjects; and the control (CON) group: 20 subjects. In all groups treatment was performed on the left hamstring muscles of the subjects for 15 minutes. We measured the relevant parameters before and after stimulation, as well as 10 minutes later. [Results] The oxyhemoglobin (oxy-Hb) and total hemoglobin (total-Hb) levels increased after stimulation in the TENS, ACU and CON groups. The increase in the oxy-Hb level in the EA group was higher (P<0.05) than that in the TENS, ACU and CON groups (in descending order). The deep muscle temperature increased in all groups. These values were higher than those in the CON group (P<0.05). The surface skin temperature increased in the EA and TENS groups. [Conclusion] These results suggest that EA us the most effective method of increasing muscle blood flow. [ABSTRACT FROM AUTHOR]

A 79-year-old male with a positive fecal occult blood test result underwent total colonoscopy, which revealed a 15-mm-semipedunculated polyp in the rectum. The polyp appeared to be an adenoma using narrow-band imaging observation in magnifying endoscopy, although a 3mm reddish segment with a different surface structure was identified adjacent to the base of the polyp. En-bloc endoscopic mucosal resection (EMR) was performed. From the pathological evaluation using the specimen, the polyp was mainly a tubular adenoma with an adenocarcinoma component within the lesion. Additionally, a tiny plasmablastic lymphoma (PBL) component, which was positive for CD45, CD79a, CD30, CD38, MUM1, and lambda light chain;negative for CD3, CD5, CD20, CD56, CD138, cyclin D1, PAX5, IgG, IgA, IgM, IgE, HHV8, and kappa light chain, coexisted near the stalk. The proliferation index using Ki-67 immunohistochemistry was approximately 80%. Furthermore, Epstein-Barr virus-encoded RNAs were identified in in-situ hybridization, although the human immunodeficiency virus was not detected. The patient received contrast-enhanced computed tomography (CT) and positron emission tomography-CT (PET-CT) follow-ups after treatment without recurrence for two years. This is the first report of gastrointestinal PBL that could be treated using EMR.

We report the rare case of a 69-year-old man who underwent resection of a mixed adenoneuroendocrine carcinoma (MANEC) of the distal bile duct and a carcinoma in situ in the perihilar bile duct. The patient was admitted to our hospital for obstructive jaundice. Imaging studies revealed a mass in the distal bile duct, and an abnormal epithelium was detected in the perihilar bile duct using peroral cholangioscopy. Bile cytology and transpapillary biopsy of the tumor revealed adenocarcinoma. We diagnosed this patient with distal cholangiocarcinoma with extensive intraepithelial progression toward the perihilar bile duct and performed a subtotal stomach-preserving pancreaticoduodenectomy and left hepatectomy. According to the histological examination of the resected specimens, we found a MANEC in the distal bile duct and a carcinoma in situ in the perihilar bile duct. Together, they were diagnosed as synchronous double primary cancers due to the lack of pathological transition between them.

A 15-mm whitish, depressed lesion was observed in the stomach of a 39-year-old using screening esophagogastroduodenoscopy. The lesion had grown to a size of 40mm and had a cobblestone-like appearance at an 11-year endoscopic follow-up. Using endoscopic submucosal dissection (ESD) as a diagnostic therapy, gastric mucosa-associated lymphoid tissue (MALT) lymphoma with MALT translocation gene 1 without Helicobacter pylori infection was detected. Although the patient did not undergo additional treatments, he remained alive without for recurrence 5 years after ESD.

An 84-year-old woman developed blepharoptosis, diplopia, weakness of extremities, and dysphagia with elevation of serum CK levels after treatment with nivolumab against renal cell carcinoma. 3 Hz repetitive stimulation showed waning in the trapezius muscle, leading to the diagnosis of myasthenia gravis. Laboratory examination showed that anti-acetylcholine receptor antibody was negative. We performed IVIg and steroid therapy. However, her symptoms did not improve, and she died of respiratory failure, although serum CK levels ameliorated to the normal range. The results of autopsy showed atrophy of muscle fibers and massive infiltration of inflammatory cells in the endomysium of the iliopsoas muscle and diaphragm, indicating occurrence of myositis. Immunohistochemical analysis showed that CD8-positive T cells mainly infiltrates in the endomysium with a small number of CD4-potive T cells. Here, we report an autopsy case of nivolumab-induced myasthenia gravis and myositis.

An 83-year-old man with main pancreatic duct (MPD) stenosis in the pancreatic body had undergone surveillance with semiannual imaging studies for 3 years. During surveillance, magnetic resonance cholangiopancreatography revealed gradual enlargement of a small cyst near the MPD stenosis and contrast-enhanced computed tomography revealed locally progressive atrophic parenchyma in the pancreatic body. On endoscopic retrograde pancreatography, the MPD stenosis was more severe than it had been at diagnosis 3 years earlier. Endoscopic ultrasonography (EUS) showed a 10-mm hypoechoic mass adjacent to the MPD stenosis. The mass was pathologically diagnosed as an adenocarcinoma using EUS-guided fine needle aspiration, and distal pancreatectomy was performed. On histopathological examination, the resected specimen was found to be a moderately differentiated 9-mm invasive ductal carcinoma. Additionally, multiple high-grade pancreatic intraepithelial neoplasms (i.e., carcinoma in situ) were detected in the MPD and branch ducts near the invasive carcinoma.

Here we report successful anesthetic management of emergency thrombectomy for a patient with undiag- nosed polycythemia vera. A 67-year-old man com- plained of numbness of the right lower limb and was diagnosed with acute artery obstruction. Emergency thrombectomy was scheduled. Preoperative blood exam revealed hemoglobin 21.0 g · dl⁻¹ (hematocrit, 63.4%). During central venous catheter placement, we con- firmed high backflow blood viscosity; blood was diluted with plasma substitute. Hemoglobin was main- tained at 14-15 g · dl⁻¹ with continuous administration of plasma substitute. On re-perfusion of the right lower limb, potassium increased to 7.6 mEq · ml⁻¹, which responded to calcium carbonate, GI therapy, and furo- semide. Surgery was uneventful and the patient was diagnosed with polycythemia vera postoperatively. As perioperative management of polycythemia vera is challenging, particularly in undiagnosed and untreated cases, efforts should be made to avoid further throm- bosis and cardiac events.

We present a case of masticatory muscle tendon- aponeurosis hyperplasia in a patient who underwent general anesthesia for gynecologic surgery. The patient's square-shaped mandible was noticed during preoperative assessment by an anesthesiologist. Further investigation revealed masticatory muscle tendon- aponeurosis hyperplasia. Anesthetic induction agents were administered, and facemask ventilation was initi- ated easily. As the anesthesiologist had predicted, the patient's mouth opening was reduced after administration of muscle relaxants, and keeping her mouth open was more difficult than when she was conscious. Nasotracheal intubation was performed successfully using a bronchoscope. Patients with muscle tendon- aponeurosis hyperplasia do not generally have associated pain, and do not know that they have a limited mouth opening. They are therefore sometimes unaware that they have the condition. Anesthesiologists need to predict that airway intubation will be difficult when the patient has a limited mouth opening associated with a square-shaped mandible.

Background: Ultrasound-guided transversus ab- dominis plane (TAP) and rectus sheath (RS) blocks are peripheral nerve blocks that diminish somatic pain of the abdominal wall and are useful for postoperative analgesia. Here, we retrospectively compared the effi- cacy of ultrasound-guided TAP and RS blocks in com- bination with continuous intravenous fentanyl for postoperative analgesia of laparoscopic colectomy., Methods: The ethics committee of our institute ap- proved the study. In our hospital, postoperative analge- sia is performed with continuous intravenous fentanyl administration at three concentrations : 12.5, 18.75, and 31.25 μg · hr⁻¹. TAP and RS blocks were applied using 30-40 ml of 0.19-0.25% ropivacaine. We selected 43 patients who underwent laparoscopic colectomy from May to October 2015. We compared the fentanyl only group (F group, n=26) and block combination group (F+B group, n=17). Statistical analysis was performed with the Mann-Whitney U test P<0.05 was considered significant Results : Patient characteristics including age, height, body weight, duration of anesthesia, and surgery did not significantly differ between the two groups. The concentration of intravenous fentanyl was significantly lower in the F+B group than in the F group (F group : 19.5±8.4μg · hr⁻¹, F+B group : 14.7?4.9 μg · hr⁻¹, P=0.02). In the present study, TAP and RS blocks significantly reduced the dose of administered fentanyl. - Conclusions : Our findings suggest that a combina- tion of TAP and RS blocks lower the dose of continu- ous intravenous fentanyl needed, and may provide better postoperative analgesia after laparoscopic colec- tomy.

Background: Tracheal suctioning is performed just before extubation to remove sputum from the trachea. Although it is an invasive procedure, its adverse effect on the airway has not been investigated because this is difficult to achieve using conventional tests or monitoring. We performed a study using the forced oscillation technique to investigate whether tracheal suctioning affects respiratory impedance (consisting of respiratory resistance and respiratory reactance)., Methods: This prospective observational study was conducted in 43 patients undergoing transurethral resection of bladder tumors under general anesthesia. Respiratory impedance (R5, R20, and X5) was measured the day before surgery and just after surgery. R5 and R20 are representative values of respiratory resistance, while X5 is representative of respiratory reactance. Participants were divided into two groups: those with or without tracheal suctioning., Results: There were no significant differences in patient backgrounds or preoperative respiratory impedance parameters. In the suctioning group, post- operative R5 and R20 were significantly higher than in the non-suctioning group (P=0.002 and 0.063, respec- tively). There was no significant difference in postop- erative X5 between the two groups., Conclusions: Tracheal suctioning caused an increase in respiratory resistance in this cohort of patients, sug- gesting that unnecessary suctioning should be avoided during surgery.

A 42-year-old woman was referred to our hospital with a diagnosis of influenza A and pneumonia out of the influenza season. Chest CT findings resembled interstitial pneumonia, but we initiated anti viral agents and antibiotics. Flexible fiberoptic bronchoscopy was performed on hospital day 3. Based on the results of an RT-PCR analysis of broncho-alveolar lavage, this patient was diagnosed as having influenza viral pneumonia. In the influenza season, we can easily suspect influenza as a differential diagnosis, even if the patient's chest CT findings resemble interstitial pneumonia. Out of the influenza season, clinicians should take into consideration influenza viral pneumonia as a differential diagnosis.

We report a case of intracardiac thrombus detected by transesophageal echocardiography (TEE). A 61-year-old man with pulmonary embolism was trans- ferred to our hospital presenting with severe respira- tory distress. Emergency surgery was scheduled to remove the thrombus identified in the right atrium by transthoracic echocardiography (TEE). Four-chamber view TEE confirmed penetration of a patent foramen ovale (PFO) to the left atrium by a thrombus ; there was no thrombus in the right ventricle or pulmonary artery. Cardiopulmonary bypass was safely established without deep hypothermic circulatory arrest and the thrombus was removed uneventfully. Subsequent TEE confirmed the absence of the thrombus. In the present case, preoperative TEE was unable to reveal the thrombus trapped in the PFO. TEE is more sensitive in identifying precise information regarding the exis- tence of thrombi. Moreover, contrast echocardiography may help detect right-to-left shunting through a PFO.

We report a case of 71-year-old female with intravenous leiomyomatosis (IVL) extending to the right ventricle. She was operated on successfully by one-stage approach involving thoracotomy and laparotomy. The important question was whether to perform IVL extraction first, or hysterectomy first; performing hysterectomy before IVL extraction may increase the risk of postoperative infection such as mediastinitis, as well as the risk of intraperitoneal hemorrhage during cardiopulmonary bypass (CPB) and tumor embolism. On the other hand, if IVL extraction is performed first, there is a possibility of bleeding during hysterectomy following CPB. Moreover, in a case of malignant disease, CPB might increase the risk of systemic metastasis. In the present case, IVL extraction was performed first, considering that hysterectomy before IVL extraction would increase the risk of intraoperative complications, and leading to a successful surgery without any problems. In rare cases, such as this one, it is important that surgeons and anesthesiologists recognize the importance of cooperation and careful surgical planning to decrease the perioperative risks.

A 65-year-old woman was suspected of having advanced gallbladder cancer based on imaging results. This was considered inoperable because it was accompanied by possible liver metastasis. To confirm the diagnosis prior to chemotherapy, endoscopic transpapillary catheterization in the gallbladder (ETCG) was performed. The bile cytology was analyzed by the cell block method, which revealed mixed adenoneuroendocrine carcinoma. Based on the cytological results, extended cholecystectomy and partial hepatectomy were performed for the metastatic lesions. Bile cytology by ETCG with the cell block method was useful for deciding the therapeutic strategy in this patient with metastatic gallbladder cancer.

Background: The use of epidural anesthesia for ablominal aortic replacement surgery may be problematic because of the amount of heparin used during the procedure, which places the patient at increased risk of epidural hematoma. We evaluated its benefits, risks, postoperative outcomes and costs., Methods: We retrospectively collected data on 93 patients who underwent Y-graft infra-renal abdominal aortic replacement at our institution between 2008 and 2010. All patients were admitted to the intensive care unit (ICU) for postoperative care. We compared the mortality rate, the time until extubation, length of ICU and postoperative hospital stay, and ICU cost of those who received epidural anesthesia comparing with those who did not., Results: Thirty-two of the 93 patients (34.4%) received epidural anesthesia, which was used for 2-5 (mean ± SD ; 3.2 ± 0.8) postoperative days. Postoperative mortality during the 2-year period was 3.3% in the group that did not receive epidural anesthesia (two patients) compared with 3.1% (one patient) in the epidural group (P = 1.00). Postoperative respiratory disorders were recorded in 1.6% of patients who did not receive an epidural (one patient) compared with 6.3% (two patients) in those that did (P = 0.27). There were no reports of epidural hemorrhage, hematoma or infection. Patients with epidurals were extubated earlier than those in the non-epidural group (mean ± standard deviation 5.5 ± 7.2 hours versus 11.6 ± 7.9 hours, respectively P < 0.001), but there were no significant differences between the two groups in terms of ICU cost or length of ICU and postoperative hospital stay., Conclusions: Epidural anesthesia during abdominal aortic replacement facilitated more rapid extubation, but did not appear to influence other aspects of patient recovery or ICU costs.

We report on the development of a simulation-based sedation training course (SEDTC). Participants were doctors and medical staff, such as operating room nurses. During the course, we identified issues that medical staff confront in the operating room (OR). Sedatives and analgesics used in the course were the same as those used during operations in the OR. The simulated scenario was that of an operation conducted under regional anesthesia. At the end of the course, participants discussed problems associated with sedation and provided input regarding sedation safety. Participants commented not only on changes in their views regarding sedation, but also on general medical safety in the OR. Our findings suggest that the SEDTC may serve as a vehicle to promote safety with respect to sedation and analgesia.

We report successful anesthetic management of a patient with pheochromocytoma using high-dose landiolol hydrochloride. A 55-year-old man was scheduled to undergo resection of giant pheochromocytoma. Epidural anesthesia was not performed due to anticoagulant therapy for lower limb thrombus. Tracheal intubation was performed with the Pentax-AWS Airwayscope. Preoperative screening revealed urine adrenaline 2.567.0 microg x day(-1) urine noradrenaline 1,734.0 microg x day(-1), and a tumor diameter of 96 x 60 mm. Catecholamine surge was controlled with 50 microg x kg(-1) x min(-1) continuous infusion of landiolol hydrochloride and IV bolus phentolamine. On tumor resection, although systemic blood pressure increased to 294 mmHg and was unresponsive to repeated phentolamine administration, the heart rate remained at 70-105 beats x min(-1) and there were no significant ST changes.

Background: The i-gel (Intersurgical, Wokingham, U.K.) is a newly developed, non-inflatable supraglottic device characterized by its soft, gel-like, and transparent mask made of thermoplastic elastomer. Although i-gel can be useful in emergency airway management during chest compression, the instability after insertion remains a problem., Methods: We investigated the effectiveness of three fixation methods using a manikin and automated chest compressor., Results: After 5-minute chest compression, i-gel without fixation was shifted by 0.56 +/- 0.17 cm, which was greater than with Durapore tape (0.28 +/- 0.08 cm), Multipore tape (0.26 +/- 0.05 cm), or a fixation strap (0.04 +/- 0.05 cm). The shift of the position was smaller with strap fixation compared to Durapore or Multipore tape fixation., Conclusions: A fixation strap may be useful in stabilizing the inserted position of i-gel during cardiopulmonary resuscitation.

Background: The purpose of this study was to compare the nitrous oxide-mediated increases in cuff pressure between a tracheal tube with a tapered cuff (Taper) or conventional high volume low pressure cuff (HVLP) utilizing a simulated pediatric lung model., Methods: The automated cuff pressures were adjusted to 10, 20, and 30 cmH2O. The Taper and HVLP were exposed to 80% nitrous oxide and cuff pressure was measured 15 and 30 minutes later., Results: The cuff pressure of the Taper was significantly lower than that of the HVLP after 15 and 30 minutes, regardless of the initial pressure., Conclusions: These findings suggest that the Taper may be more effective than the HVLP in preventing hyperinflation of the tracheal tube cuff in response to nitrous oxide exposure in children.

Unique risks are involved in tracheal intubation with a laryngeal granuloma lodged in the subglottis and special precautions must be taken to manage such intubation. Reported is a case of laryngeal granuloma, which was detached from the larynx by the intubation. We discuss the management of tracheal intubation in the aforementioned case.

Famous geologist Nicolaus Steno (1638-1686) was known as a skillful anatomist in his time. His main work about anatomy is "Elementorum myologiae specimen, seu musculi descriptio geometrica". Steno introduced geometrical representation into muscle study. His purpose was to handle muscle movements in the style of Cartesian mechanical philosophy, assuming muscle fibers as the structural and functional unit of muscle. Steno modelled muscles as parallelepiped integrations of fibers. Steno thought the shortening of muscle fibers modified parallelepiped integration and its modification resulted in muscle movements. His parallelepiped model enabled the regarding of muscles as objects of physics. Steno's assumption and model built a methodological foundation of mechanistic physiology of muscle, and influenced latter 17th century thinkers, especially Borelli.

A 60's man underwent a medical check-up and esophagogastroduodenoscopy revealed an exposed-type tumor at the ampulla of Vater. Endoscopic ultrasonography and intraductal ultrasonography showed a hypoechoic mass limited to the ampulla of Vater. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a slightly dilated ventral pancreatic duct not connected to the dorsal duct. Endoscopic papillectomy was performed without pancreatic stent placement and his postprocedural course was uneventful. The specimen was histologically diagnosed as well-differentiated adenocarcinoma limited to the mucosa of the ampulla of Vater. Endoscopic papillectomy without pancreatic stent placement can be performed without a risk of post-ERCP pancreatitis for ampullary tumor limited to the mucosa of the ampulla of Vater associated with pancreas divisum.

A 78-year-old woman seen in June 2005 for chest abnormal shadows after 3 months of steroid therapy for vasculitis associated with antineutrophil cytoplasmic autoantibodies was found in chest computed tomography (CT) revealed bronchiectasis and small nodules in the right middle lobe and left lingula. Sputum cultures were positive for Mycobacterium intracellulare. Based on a diagnosis of pulmonary nontuberculous mycobacteriosis, the woman underwent antimycobacterial therapy with clarithromycin, rifampicin, and ethambutol hydrochloride for 10 months. She was then admitted in June 2009 with right chest pain. Chest CT showed consolidation shadows with bronchiectasis in the right middle lobe and the left lingula and left pleural effusion. Magnetic resonance imaging (MRI) showed that Th7-Th8 vertebral bodies had collapsed. A vertebral body specimen obtained by CT-guided biopsy was positive for M. intracellulare. Based on a diagnosis of vertebral osteomyelitis due to M. intracellulare, she underwent antimycobacterial therapy with clarithromycin (800 mg), rifampicin (450 mg), ethambutol hydrochloride (750 mg), and streptomycin (750 mg). After 4 weeks of antimycobacterial therapy, she underwent radical debridement and decompression surgery with anterior and posterior spinal fusion. Four weeks postoperatively, streptomycin was discontinued. We continued clarithromycin, rifampicin, and ethambutol hydrochloride for 18 months, and no recurrence was detected. Although vertebral osteomyelitis due to nontuberculous mycobacteria is rare, clinicians should consider the combination of nontuberculous mycobacteriosis and vertebral osteomyelitis in cases such at these.

Background: Deep vein thrombosis (DVT) is the main cause of pulmonary thrombolism (PE). Thus by preventing DVT, the risk of PE can be greatly reduced., Methods: Patients were divided into two groups: a group of patients who were affected with DVT after total hip arthroplasty (THA) and a group of patients who were not affected. To examine the risk factor for DVT after THA, a comparative analysis between these two groups was performed., Results: According to the multivariate logistic regression analysis, the preoperative elevated value of D-dimer is a significant risk factor which is only relative to the onset of DVT after THA. In addition, it was suggested that the preoperative value of D-dimer could be used as a means to rule out DVT after THA., Conclusions: It is useful to investigate the preoperative value of D-dimer as a predictive factor for the occurrence of DVT after THA.

This is a report of a patient with paroxysmal nocturnal hemoglobinuria (PNH) undergoing laparoscopic colon surgery. Preoperative examination showed pancytopenia, paroxysmal atrial fibrillation and slight renal function disorder. Heparin calcium was used to prevent venous thrombosis, because this case had several risk factors; advanced age, major surgery for cancer, PNH and long term medication with steroid. Washed red blood cells were transfused preoperatively. During the operation, total intravenous anesthesia was used. We prevented acidosis and other factors of thrombosis, and transfused washed red blood cells to correct anemia. During the postoperative course, red blood cells transfusion was required, but this case showed no obvious hemolysis, bleeding or venous thrombosis.

We experienced a case of an endocarditis with persistent fever despite appropriate antibiotic therapy. Intraoperative transesophageal echocardiography showed bicuspid aortic valve with vegetations which caused a severe aortic regurgitation. Furthermore, a new abscess formation extending to the aortic annulus was detected by transesophageal echocardiography. A stentless valve was used to reconstruct the aortic valve with a subcoronary method. Patients with bicuspid valve infectious endocarditis incur high risk of abscess formation. It is important to have frequent observation of the infected valve preoperatively and careful observation during operation to detect further abnormalities which may cause alteration of the procedure.

A 30-year-old woman with chest discomfort at swallowing and occasional vomiting was referred to our department with a diagnosis of esophageal submucosal tumor. CT visualized a mass 70 mm in diameter in the middle esophagus. Esophagogastroduodenoscopy revealed a pedunculated submucosal tumor, and endoscopic resection was considered. As the size of the tumor was so large, retrieval of the resected specimen via the stomach following incision, laparotomy was planned. En bloc resection by endoscopic submucosal dissection with a Hook-knife was performed. Retrieval of the resected specimen was carried out as planned. The specimen, which was 53×48×43mm in size with a distinct margin, was diagnosed as leiomyoma derived from the muscularis mucosae histologically. Her postprocedural course was uneventful. Endoscopic resection can be chosen when an esophageal submucosal tumor is pedunculated with abundant mobility, making it possible to avoid invasive surgery.

Background: It has been reported that postanesthetic shivering is associated with general anesthesia using remifentanil infusion. The aim of this retrospective study was to evaluate the factors leading to postanesthetic shivering., Methods: The patient populations include patients who had undergone laparoscopic colectomy under total intravenous anesthesia with propofol, remifentanil infusion and fentanyl bolus administration. Preoperative clinical variables of interest included age, sex, height, weight, and body surface area. Intraoperative variables of interest included the duration of anesthesia and surgery, pharyngeal temperature at the beginning and the end of the surgery, predicted plasma and effect site concentration of fentanyl at the extubation and mean infusion rate of remifentanil., Results: The authors identified 53 patients and 9 of them had shown shivering. In shivering group, the duration of anesthesia and surgery was significantly longer, and the predicted plasma and effect site fentanyl concentrations in extubated period were significantly lower. There was no significant difference in either background or core temperature., Conclusions: These data suggest that fentanyl concentration may be important for avoiding postanesthetic shivering and the duration of surgery may be a predictor for postanesthetic shivering.

In the second decade of the Showa period, great changes were made in the Japanese anatomical terms. It has been proposed that the presentation of JNA (Jenaer nomina anatomica) was one of the factors leading to the change. The Japanese language reform campaign, however, played an important role. The party kokugoaigo doumei and its successor kokugo kyokai required concise and unified technical terms. The anatomical nomenclature committee of the Japanese Association of Anatomists worked to satisfy this requirement. The committee consulted with nomenclature committees of other medical associations and took account of their opinions. The anatomical nomenclature committee abandoned the literal translation from Latin to Japanese and shaped a succinct Japanese terminology. Modern Japanese anatomical terms are based on this terminology.

Hepatectomy is accepted as the standard therapy in patients with resectable liver metastases. In recent years, the techniques such as microwave coagulation therapy (MCT) and radiofrequency ablation therapy (RFA) have been developed, so we have many options to treat. We evaluated nineteen subjects with cases of liver metastases who underwent thermoablative procedures with or without hepatectomy. RFA and MCT were used in 6 cases and 2 cases, respectively. In other 11 cases, they received a combined therapy: RFA+hepatectomy in 5 cases, and MCT+hepatectomy in 6 cases. Thermoablative therapy was used for 39 metastatic tumors. The mean tumor size was 13.7 mm, and a local recurrence was observed in 8 nodules (21%). No significant differences were observed in DFS and OS between thermoablative therapy and hepatectomy. Many patients with liver metastases received a repeated treatment, so we have to care about the remnant liver function. We conclude that thermoablative therapy with hepatectomy seems to be a less invasive procedure and effective therapy.

A 64-year-old man presented with chronic cough. Chest CT revealed a nodular shadow with cavitation in the right S6. Seven months after his first examination, the nodular shadow had gradually increased, so flexible fiberoptic bronchoscopy was performed. The results of bronchial brushing and aspiration cytology were negative, however, gram-stained smear of the bronchial aspirate revealed many gram-positive rods with branching filamentous hyphae and culture of the bronchial aspirate was positive for the Actinomyces species. On a diagnosis of pulmonary actinomycosis, 1500 mg of oral amoxicillin was initiated. After 4 months of treatment, the right S6 nodule size was unchanged and the level of CYFRA in serum was elevated. Therefore, video-assisted thoracic surgery (VATS) was performed. A histological examination of the resected tumor showed papillary and acinar adenocarcinoma. The common radiological features in patients with pulmonary actinomycosis are nodules, mass formation and cavitation. Pulmonary actinomycosis requires differentiation from lung cancer. Although lung cancer with coexisting pulmonary actinomycosis is rare, clinicians should take into consideration the fact that lung cancer and pulmonary actinomycosis can co-exist in the same patient.

A 56-year-old woman was admitted to our department for further evaluation of a hypoechoic mass in the pancreatic head detected by abdominal ultrasonography during a medical check-up. Abdominal and endoscopic ultrasonography demonstrated a demarcated round hypoechoic mass 15 mm in size without dilation of the main pancreatic duct, and ERP showed a normal main pancreatic duct and branch duct. Because pancreatic cancer was strongly suspected based on dynamic CT and MRI findings, she underwent pancreatoduodenectomy. Pathologically, the tumor was diagnosed as well-differentiated adenocarcinoma in the pancreatic head, 13 mm in diameter, 10mm apart from the main pancreatic duct. The main pancreatic duct was completely free of cancer cells and the origin of the cancer was considered to be the epithelium of a peripheral branch duct.

Histopahological features of rheumatoid arthritis, beginning from synovitis through deteriorating cartilage and bone to joint destruction has basically unchanged since the old days. On the other hand many inflammatory factors initiating, sustaining and/or activating inflammation such as cytokines and proteolytic enzymes, were successively detected, and followed by genetic analysis using animal models such as transgenic and knockout methods. Newly developed therapies by biological products remarkably have influenced the inflammatory these factors and genes, and seemed to modify the histopathological features. This article refers the histopathlogical features of RA in topics such as places involved in early stage, and the cellular origin, especially about the fibroblast like cells (FLS) which have been paid attention recently as key cells presenting immunological, histiocytic and fibroblastic properties, furthermore, participating the bone destruction in part as well as osteoclast in RA. We also introduce the several animal models of RA applied by many researchers for therapeutic and genetic analyses in RA.

Ceftazidime (CAZ), a cephem antibiotic for injection, was administered at dose of one gram q.i.d. to adult hospital-acquired pneimonia patients, and the clinical efficacy and blood concentration of CAZ was studied in five cases. The assessment of clinical efficacy was "efficacy" in all cases, and early improvement of examination value including body temperature, the value of CRP, and white blood cell counts were obtained. Abnormality of hepatic function as adverse effect was noted in two cases. However, the severity was mild and didn't affect the treatment in both cases. The maximum drug concentration immediately after the end of infusion was 72.1-176.5 microg/mL (median, 82.7 microg/mL) and the trough level was 5.1-72.1 microg/mL (median, 26.6 microg/mL), therefore the blood concentration was maintained a higher level than the MIC of bacteria estimated to be causative. From these results, administration method of ceftazidime one gram q.i.d. was considered to be a good way with increase of drug efficacy by maintaining highly blood concentration over prolonged period, and expected to be a good effect for hospital-acquired pneumonia.

We encountered a patient with atrial septal defect (ASD) of sinus venous type which had not been diagnosed preoperatively. A 70-year-old-man with angina pectoris was admitted to our hospital and coronary artery bypass grafting was scheduled. After induction of general anesthesia with fentanyl, propofol, midazolam, and vecuronium, operation was going smoothly. However, we found an abnormal rise of the value of Sv(O2). Transesophageal echocardiography (TEE) demonstrated ASD of sinous venous type which had not been diagnosed preoperatively. For this incidental diagnosis, operation was performed to repair ASD and was finished successfully. He was discharged from the hospital on postoperative day 18 without complications. We have demonstrated in this report that TEE is an important tool which should be used routinely to diagnose cardiac diseases which have not been diagnosed preoperatively.

Japanese anatomical terms (butterfly-shaped bone) have an interesting history. Galen named a bone (wedge-like). This Greek term was introduced into Latin anatomical texts by transcribing into 'os sphnoides' or translating it as 'os cuneiforme'. Both terms mean equally wedge-like bone. From 16th century on, these two terms prevailed in European anatomical textbooks, but in 18th century some anatomists merged this bone with some kinds of winged creatures and named their wings "Ala major' and 'Ala minor'. In mid-19th century English-Chinese anatomical book, this bone was named (butterfly bone) by a medical missionary Benjamin Hobson. This term was introduced into Japanese textbooks. In Meiji Era both terms were used in Japanese textbooks, and (wedged-like bone). Some anatomists insisted on using because this echoed original Latin term's sense. Eventually, Japanese Associations of Anatomists adopted in 1943.

Lymphoepithelial cysts occur mainly in the lateral cervical region, but rarely in the parotid gland. We report three cases of lymphoepithelial cysts arising in the parotid gland. These patients presented with a mass in the pre-auricular or infra-auricular region. All masses were mobile and non-tender. The lesions were removed by superficial partial parotidectomy. A definite diagnosis could not be made at initial evaluation, including clinical findings, ultrasound sonography, computed tomography, magnetic resonance imaging, nor radioisotope scintigraphy. Final diagnoses were made by histopathologic evaluation of the excised specimen. In these three cases, histopathologic examination of the mass showed a cystic lesion to be lined by stratified squamous or cuboidal epithelium that was surrounded by a lymphoid tissue with lymphoid follicles, leading to a histopathological diagnosis of lymphoepithelial cyst. The postoperative course was uneventful, and there has been no evidence of recurrence in any of the three cases reported. A review of 52 cases of lymphoepithelial cyst arising in the parotid gland reported in Japanese literature was also made together with the three cases of lymphoepithelial cyst arising in the parotid gland reported here. The results of this review were considered clinical presentation and histopathogenesis of the three cases of lymphoepithelial cyst arising in the parotid gland reported here.

We report a case of intraoperative systolic anterior motion (SAM) of the mitral valve after mitral valve plasty (MVP). A 53-year-old man underwent MVP for mitral regurgitation (MR). MVP was carried out uneventfully. We weaned the patient from cardiopulmonary bypass (CPB) with continuous administration of catecholamines and a vasodilator. However, after the weaning from CPB, transesophageal echocardiography (TEE) detected moderate MR with left ventricular outflow tract obstruction (LVOTO) due to SAM. LVOTO and SAM gradually disappeared after the reduction of catecholamines and volume loading. He was transferred to the intensive care unit postoperatively and extubated 18 hours after operation. Transthoracic echocardiography after operation revealed disappearance of MR. He was discharged from the hospital on postoperative day 15 without complications. We successfully managed MR with LVOTO due to SAM by reduction of catecholamines and volume loading.

We report 3 cases of acute pulmonary thromboembolism (PTE) diagnosed by transesophageal echocardiography (TEE). In all these cases, cardiovascular state of the patient was unstable and therefore computerized tomography and catheterization of the pulmonary artery for diagnosis of PTE could not be performed. TEE was useful for diagnosis of acute PTE. All three patients passed away eventually and we had a difficult experience for treatment of acute PTE. We should take various measures against deep vein thrombosis for prevention of acute PTE.

We describe a19 year-old woman who was diagnosed as systemic lupus erythematosus (SLE) after abortion. She had taken anti-convulsants for epilepsy since she was 8 years old. Induced abortion surgery was performed at six weeks in her pregnancy. She showed pyrexia and a general rash 2 days after the abortion. She was introduced to our hospital because the administration of antibiotics was not effective. Since the anti-convulsants had been changed after pregnancy, we returned to those administered before pregnancy and followed her up. Her eruption improved, but she became aware of thirstiness and dry eye. She was diagnosed as Sjögren syndrome by ophthalmologic examination, lip biopsy, and elevation of an anti-SS-A antibody and an anti-SS-B antibody in the serum. Since we could not rule out SLE because of the low concentration of complement activity in blood, we followed her up carefully by checking serum markers of SLE. Protein urine developed after the improvement of the eruption 2 weeks later. Low complement activity was recognized and double stranded (ds)-DNA antibody became positive. In addition to these findings, she had an episode of hypersensitivity to sunlight and was therefore diagnosed as SLE. Since induced abortion and drug eruption might be associated with the onset of SLE, the case is thought to be a valuable from the view point of understanding the mechanism of SLE onset.