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We conducted a systematic review to examine whether step-down of inhaled corticosteroid (ICS) is recommended for adult patients with asthma have been well controlled with moderate or high-dose inhaled corticosteroids for more than 12 weeks. Seven randomized controlled trials were included. ICS step-down did not increase asthma exacerbations requiring systemic steroid therapy and hospitalization. There was no effect on respiratory function, asthma control, or QOL. No significant differences were observed in serious adverse events or steroid-related adverse events, but the observation period was insufficient to assess long-term effects. Based on these results, we weakly recommend ICS step-down in adult patients with asthma have been well controlled with moderate or high-dose inhaled corticosteroids, but long-term asthma control and the incidence of steroid-related adverse events should be further investigated in the future.

Esaxerenone is a novel non-steroidal mineralocorticoid receptor antagonisit (MR blocker), whose unique binding to the MR-ligand domain yields a stronger MR antagonistic effect and higher selectivity than existing MR antagonisits. Esaxerenone was approved for the treatment of hypertension in Japan in January 2019. Esaxerenone suppresses the reduction of urinary Na+/K+ ratio in adrenalectomized rats and blood pressure increase, proteinuria, and renal tissue lesions in salt-sensitive hypertensive rats-all in a dose-dependent manner. Esaxerenone is rapidly absorbed and reaches intracellular targets because of its high membrane permeability, exhibits high bioavailability with small interindividual exposure variation, and is metabolized via several pathways (e.g., oxidation, glucuronidation, and hydrolysis), which is associated with low drug-drug interaction risk. As esaxerenone is slightly excreted into urine, its exposure is similar between elderly and non-elderly patients, and between patients with normal and moderately deteriorated renal function. Given its 19-hour half-life, once-daily administration would have a sustainable antihypertensive effect. The ESAX-HTN phase 3 study demonstrated the non-inferiority of esaxerenone's antihypertensive effect versus that of eplerenone in essential hypertension. Another study showed a stable antihypertensive effect for 52 weeks as monotherapy or combination therapy. In hypertensive patients with moderate impairment or both type 2 diabetes and albuminuria treated with a renin-angiotensin system inhibitor, esaxerenone elicited a stable antihypertensive effect and manageable hyperkalemia incidence with titration from a low dose and monitoring including serum potassium. Thus, with careful monitoring of serum potassium, esaxerenone can be administered to patients with moderate renal impairment or both diabetes and albuminuria.

Neoadjuvant chemotherapy(NAC)is a promising approach for the improvement of gastric cancer treatment outcome. S-1 plus cisplatin(SP)or S-1 plus oxaliplatin (SOX)is generallythe first choice of NAC regimen. We experienced that NAC with ramucirumab(RAM)plus paclitaxel(PTX)was effective in locallyadvanced gastric cancer, but that with SOX was ineffective. A 68-year-old man developed locallyadvanced gastric cancer and received NAC with SOX, which was stopped because of tumor enlargement. The patient was then given NAC with RAM plus PTX, which was effective and enabled radical excision. Anti-angiogenic agents maycause wound healing complications, which mayincrease the risk of leakage. However, he was discharged without postoperative complications. Therefore, RAM plus PTX can be a promising NAC regimen for locallyadvanced gastric cancer.

Background: While systemic therapy is one of the therapeutic options available for post-operative recurrence of non-small cell lung cancer, efficacy of local therapy for locoregional recurrence or limited metastatic lesions has also been reported., Objective: We aimed to evaluate the clinical course of patients with post-operative recurrence(locoregional or limited metastatic lesion)after receiving local or systemic therapy., Methods: Clinical data were retrospectively analyzed and survival duration was compared using the logrank test., Results: A total of 22 patients were included. Median progression-free survival in patients receiving local therapy, systemic chemotherapy, or a combination of both therapies was 15.1 months, 6.3 months, and 13 months, respectively. Two patients receiving treatment with EGFR-TKI did not show disease progression at 41.3 months and 45.8 months(p=0.265). Median overall survivals in patients receiving local therapy, systemic chemotherapy, or a combination of both therapies were 26.5 months, 20 months, and 37.9 months, respectively(p=0.510). After the treatment, 6 patients showed regrowth of the recurrent lesion, 8 patients showed remote metastases, and 2 patients showed both regrowth of the recurrent lesion and remote metastases., Conclusion: Patients who received treatment including local therapy showed longer survival duration, but statistical significance was not detected. Our study suggested that regrowth of the recurrent lesion and remote metastases can be equally observed after treatment.

A 35-year-old female, professional diver, reported nausea, vomiting, and systemic hives 20 to 30 minutes after ingestion of antipasto made with jellyfish. Patient reported prior episodes of swelling after stings from several different creatures, including jelly fish. She also developed a systemic allergic reaction after sting from an unknown creature while diving. On the initial visit to our hospital, serum total IgE level was 545IU/ml. We extracted crude allergen from jellyfish and evaluated allergen specific IgE antibody levels using ELISA. Patient samples showed higher levels of jellyfish-derived allergen specific IgE than healthy control samples. Basophils were isolated from the peripheral blood of patient. Stimulation with jellyfish-derived allergen showed expression of surface antigens on basophils increased in a concentration-dependent manner. Methods using sodium dodecyl sulfate poly acrylamide gel electrophoresis and immunoblotting showed acid-soluble collagen fraction from jellyfish contained above 250kDa weighed protein that may have caused this current event. A provocation test using jellyfish samples was not performed due to risk of anaphylactic shock. The patient was diagnosed with a jellyfish allergy due to IgE mediated anaphylaxis after ingestion. She was asked to refrain from consuming any food containing jellyfish. IgE-mediated food allergy caused by jellyfish is rare worldwide. Collagen was speculated to be an allergen in this study. Additional study to detect specific allergens related to jellyfish allergy would be particularly useful to specify disease phenotypes and individual care in future.

A 79-year-old man experienced severe chronic obstructive pulmonary disease (COPD) and was receiving treatment for ischemic heart disease. Starting from dizziness and chilliness, he lost consciousness after few days. He was taken to our emergency department. On initial evaluation, he complained of dyspnea and was afebrile with a pulse rate, blood pressure, and respiratory rate of 105 beats/min, 112/98mmHg, and 28 breath/min, respectively. His respiratory sounds were clear and chest radiography did not show any abnormal shadows, but his arterial blood gas examination showed type II respiratory failure. Because the nasopharyngeal seasonal influenza A virus (IAV) test was positive, the patient was admitted with the diagnosis of acute exacerbation of COPD due to IAV. We administered peramivir, a specific anti-influenza drug, and started mechanical ventilation. Over time, he started to show signs of disseminated intravascular coagulation, such as multiple organ failure and thrombocytopenia. Subsequently, blood tests showed elevation of ferritin and soluble interleukin 2 receptor (sIL2R); microscopic examination of the peripheral blood revealed hemophagocytosis. Secondary hemophagocytic lymphohistiocytosis (HLH) due to IAV was diagnosed and together with corticosteroid therapy, intravenous gamma globulin was administered from the 3rd clinical day. The patint was saved with our early diagnosis and treatment of HLH and was discharged on the 92nd clinical day. Viral-induced HLH, formerly known as virus-associated hemophagocytic syndrome (VAHS), leads to multiple organ failure due to a cytokine storm scattered by viral-infected pathogenic inflammatory cells. It is well known that pandemic swine flu causes secondary HLH leading to poor outcomes. Currently, not much is known about HLH due to seasonal flu; particularly, IAV (H3N2)-related HLH cases are rare and reported cases showed poor outcomes as well. With an early diagnosis and minimum immunotherapy, we report herein on a case of IAV (H3N2)-related HLH which was treated successfully.

Chronic respiratory disease, such as chronic obstructive pulmonary disease(COPD)continues to cause a heavy health and economic burden in the world. Lower-limb muscle dysfunction is a prominent and major extrapulmonary features in individuals with moderate-to-very severe COPD and has important clinical implications, such as reduced exercise tolerance, activity of daily living(ADL), health related quality of life(HRQOL)and even survival. Osteoporosis is also an important systemic feature of COPD. Osteoprotic fracture cause many symptoms and complications, including the impairment of ventilation, and create a heavy economic burden. Comprehensive treatments(drug medication and non-drug treatment)for these impairments, such as pulmonary rehabilitation, are recommended. Pulmonary rehabilitation improves dyspnea, exercise capacity, ADL, and HRQOL, each of which is recognized predictors of mortality.

Objectives: In the present study, we aimed to clarify the specific effects of age, period, and cohort on trends in obesity rate and energy intake ratio from fat in Japanese adults using a Bayesian age-period-cohort (APC) analysis and to evaluate the relationship between changes in obesity rate and energy intake ratio from fat., Methods: We obtained data regarding obesity rate and calorie intake of fat, animal fat, carbohydrate, protein, animal protein, and total energy intake of Japanese adults from the National Nutrition Survey. The data were tabulated for five 10-year age groups (from 20-29 years to 60-69 years) and 17 annual demographic profiles (from 1995 to 2011), with regard to the energy intake ratio. These standard cohort tables were analyzed using a Bayesian APC model., Results: With regard to obesity rate, the effect of age was the greatest and increased rapidly in the age group of 30-39 years for both genders. Moreover, the period effect consistently increased in men, but had very little variation in women. The cohort effect indicated a reverse of the decreasing trend in the cohorts born after 1962-1971 in men and indicated a reverse of the increasing trend in the cohorts born after 1965-1974 in women. With regard to the energy intake ratio from fat, the trends for the three effects differed from those for obesity rate for both genders. The age effect generally decreased with increasing age. Furthermore, for both genders, the period effect gradually decreased after 1998 and markedly decreased in 2001, remained constant or slightly increased until 2008, and increased thereafter. However, the cohort effect was the greatest among the three, and although a decreasing trend was observed in the cohorts born after 1976-1985 in women, the energy intake from fat increased in the younger cohorts in both genders. The overall effect on energy intake ratio from animal fat had a slope similar to that of the energy intake ratio from fat., Conclusion: Each effect affected obesity and energy intake ratio from fat in a different manner, suggesting that factors other than energy intake ratio from fat, such as energy expenditure, contributed to the changes in obesity rate. However, obesity risk markedly increased in the age group of 30-39 years, and younger generations had a higher energy intake ratio from fat. These results suggest that dietary guidelines, particularly the optimal intake of animal products, is needed for younger generations to prevent the development of obesity in adulthood.

We report the autopsy case of a 74-year-old woman. Onset of gait disturbance and left-side dominant bilateral motor disturbance in the patient led to bilateral progressive apraxia. This was associated with a decline in motor imagery, right-side dominant atrophy of the central sulcus region, and a decrease in cerebral blood flow during illness. She died of respiratory failure that had progressively worsened over a 9-year period. Pathologically, she exhibited right-side dominant cerebral atrophy; neuronal loss, gliosis, and astrocytic plaques were mainly present in the frontal lobe. She was subsequently diagnosed with corticobasal degeneration (CBD). The premotor and primary motor areas revealed marked degeneration; in addition, severe myelin pallor was observed in these regions, and it was suggested that such pathological features were responsible for the apraxia. We believe the present case is valuable since very few reports have provided a detailed description of clinicopathological apraxia in association with CBD.

A 30-year-old woman had refractory asthma. She had also experienced twice severe anaphylaxis episodes after ingesting peaches. The patient was extremely wary about reoccurrence of anaphylaxis and avoided ingesting any fruits, including peaches. She visited our hospital for testing and treatment for asthma and the peach allergy. Skin and serologic testing showed that she had a severe allergy to house dust, mites, and peaches. The food challenge test results showed that ingesting 6.5 g of the peach fruit induced dyspnea in the patient. Her asthma could not be controlled despite treatment involving a leukotriene receptor antagonist and combination inhalation of high-dose salmeterol xinafoate/fluticasone propionate. We advised the patient to keep strict avoidance ingesting peaches because of her food allergy. However, she hoped to overcome her food restrictions, especially those for fruits. We initiated treatment involving the recombinant humanized monoclonal anti-IgE antibody omalizumab (150 mg, once a month) to ensure that the asthma was controlled well and to improve the patient's diet. The asthmatic symptoms ameliorated, and the peak expiratory flow increased in a short time. We gradually reduced the restriction on peach consumption. This was achieved by rechallenging the patient with increasing doses of 290 mg of the peach fruit and was initiated at 28 weeks after starting omalizumab therapy. The restriction on peach consumption was lifted eventually, and the patient did not experience any allergic symptoms subsequently on ingesting peaches. Thus, for our patient, omalizumab therapy was highly effective in achieving remission from both asthma and peach allergy.

A 78-year-old man referred to our hospital with the chief complaints of anorexia, general malaise, rash, and weight loss. Laboratory examination revealed pancytopenia, hyperglobulinemia, generalized adenopathy, and multiple pulmonary nodules. Video-assisted thoracic surgery (VATS) was performed to diagnose pulmonary nodules. After operation, it was difficult to achieve hemostasis for a while. Finally, the patient was diagnosed as pulmonary cryptococcosis and Evans syndrome.

We inspire air and get oxygen, and the storaging conditions of the oxygen in the blood are gas and solid (Hb-O2) type. To measure the gas type oxygen in the blood, we use blood gas analyzing meters, and we also can measure solid type oxygen by this method. From this method, we can get arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), pH, HCO3(-), and so on. By the way, pulse oximeter is an equipment to measure percutaneous arterial oxygen saturation (SpO2). Although the PaO2 and SpO2 are essential parameters to know the clinical conditions of COPD patients, we should be aware of the primary differences between them, and use these parameters effectively.

A 54-year-old man who had been treated hypertension admitted our hospital due to midbrain hemorrhage. Pulmonary abnormal shadow was also found by chest radiological examinations and it was diagnosed as stage IB (T2N0M0) non-small-cell lung cancer. Right upper lobectomy with combined resection of azygos vein and parietal pleura facing to the tumor was conducted because the direct invasion of the tumor was strongly suspected. Pathological diagnosis was pleomorphic carcinoma. Although, postoperative course was uneventful, midbrain hemorrhage recurred 3rd postoperative day. Since the hemorrhage continued in spite of the conservative treatment, the craniotomy was performed on the 13th postoperative day. The pathological examination revealed the hemorrhage to be caused by the brain metastasis.

The incidence of dementia with Lewy bodies (DLB) is increasing rapidly due to the increasing longevity of the population. In DLB, autonomic dysfunction, such as sleep disorders, and cardiopulmonary arrest, together with unconsciousness, can occur. Such cases have poor prognosis and may have dysfunction of chemosensitivity in the respiratory center. We have assessed the function of the respiratory center, especially chemosensitivity to hypercapnia. Twelve probable DLB patients (Group 1) and twelve age-matched healthy subjects (Group 2) were examined. Chemosensitivities to hypercapnia expressed by delta expiratory volume/delta partial pressure of carbon dioxide/body surface area: mean 0.16 (1/min/Torr/m(2)) in Group 1 and 0.49 in Group 2. Thus, patients with DLB had a subnormal hypercapnic response in chemosensitivity of the respiratory center, suggesting dysfunction of the respiratory center. Respiratory center dysfunction may be related to cardiopulmonary arrest together with unconsciousness, so, patients with DLB should not use drugs affecting the respiratory center.

The purpose of this study was to determine whether the level of physical activity (as measured by 12 functional physical fitness tests) differed between patients with chronic obstructive pulmonary disease (COPD) and normal subjects. Fifty male patients with COPD (70.4 +/- 7.1 yr) and 193 age-matched normal subjects (71.2 +/- 5.2 yr) participated in the study. We administered twelve functional physical fitness tests that were designed to represent muscle strength, muscular endurance, reaction, flexibility, balance, regulation and manipulation. Cardiorespiratory fitness was measured by an incremental, symptom-limited exercise test to the maximal tolerable level on a cycle ergometer, and by the 6-min walk distance. Further, we evaluated what the relationships were between cardiorespiratory fitness and physical activities. The results showed that there were significant differences between COPD and normal groups in cardiorespiratory fitness [peak oxygen uptake (15.7 +/- 4.8 ml/kg/min vs. 23.9 +/- 6.5 ml/kg/min, p < 0.05), peak load (77.9 +/- 33.7 watts vs. 110.3 +/- 37.9 watts, p < 0.05) and 6-min walk distance (466.4 +/- 106.3 m vs. 540.4 +/- 78.3 m, p < 0.05)] and muscular endurance [arm curl (22.6 +/- 5.0 rep/30 s vs. 25.2 +/- 6.0 rep/30 s, p < 0.05), Keeping a half-squat position (32.6 +/- 16.4 s vs. 42.8 +/- 17.7 s, p < 0.05)] and regulation (27.2 +/- 9.4 s vs. 23.3 +/- 5.8 s, p < 0.05) in functional physical fitness test. There were significant correlations between cardiorespiratory fitness, and muscular endurance and regulation. Furthermore, there were significant correlations between FEV1.0 and FEV1.0% pred, and regulation. Therefore, it is important that, besides exercise prescriptions based on the criteria of symptom-limited exercise tests, development of exercise programs based on the level of physical activities may be necessary for patients with COPD.

We succeeded in distinctly imaging the calf veins using Gd-enhanced subtraction MR venography (Gd SMRV). Gd SMRV was performed in 15 normal legs, 33 varicose legs and 22 legs with suspected deep venous thrombosis. Conventional venography was performed in 46 legs in all. The deep veins of the calf, greater saphenous vein, and intramuscular veins had high rates of demonstration in normal legs and varicose legs (84, 100%, 87, 97%, 67, 73%). The varices were also well demonstrated (100%). When Gd SMRV was compared with conventional venography in terms of diagnosis of calf venous thrombosis, the sensitivity of this method was 100%, specificity was 92% and accuracy was 93%. We found high intensity thrombi on precontrast images in most cases, a finding that was important for the diagnosis of local thrombi. This method was non-invasive and was able to clearly visualize veins in the calf. We concluded that Gd SMRV was useful for calf venous disease, especially calf venous thrombosis.

A 44-year-old man was admitted to the hospital with dyspnea on exertion. Chest radiographs and pulmonary function tests showed evidence of pulmonary emphysema. Serum alpha 1-antitrypsin (alpha 1-AT) could not be detected by nephelometry, immuno-electrophoresis, or iso-electric focusing. However, allele-specific PCR revealed a genotype homozygotic for an alpha 1-AT deficient variant of the Siiyama allele. An elder sister of the proband was also a homozygous carrier of the Siiyama allele. The amino acid sequence for normal alpha 1-AT variants had been substituted by Arg101-Val213-Glu376 in the proband, demonstrating that the alpha 1-antitrypsin-deficient Siiyama variant in this pedigree was derived from M 1 (Val213).

Seventeen patients with clinical stage I lung cancer were given irradiation therapy with heavy ion radioactive rays at 73.1 +/- 11.2 GyE. Lung injury due to irradiation was evaluated by measuring routing parameters of pulmonary function. No statistically significant changes in these parameters were observed after irradiation, even in patients followed up for a period of 1 year. Chest X-ray examinations, including CT scan images, disclosed the development of nonsegmental consolidations in the irradiated areas, changing into minor fibrosis 1 year later. We concluded that heavy ion particle irradiation has minimal impact on pulmonary function, and is of therapeutic valve to elderly patients and patients with complications.

To evaluate the long-term effects of pulmonary rehabilitation on physiological outcome, 12 patients with pulmonary emphysema were enrolled in an inpatient pulmonary rehabilitation program for 6 weeks. After discharge from the hospital, they were followed up for 1 year. The pulmonary rehabilitation program consisted of breathing retraining, thoracic mobilization, exercise training, and patient education. Although the subjects did not participate in outpatient maintenance group sessions after their discharge, they continued breathing retraining and exercise training at home. Their vital capacity improved significantly, and was sustained over the course of the year; other pulmonary functions, however, did not change significantly. Maximum exercise load increased 31% after the rehabilitation program; although it was 18% higher than baseline at follow-up one year later, that was not a significant change. The follow-up data on exercise traming had generally deteriorated 1 year after the rehabilitation program. The change in maximum exercise load from baseline before and after the inpatient pulmonary rehabilitation program correlated closely with the change in maximum exercise load thereafter to follow-up one year later (R = 0.62). We conclude that it is pessible to estimate long-term change in exercise capacity on the basis of short-term changes achieved during inpatient pulmonary rehabilitation. It may be necessary to develop maintenance programs of some kind to help pulmonary emphysema patients retain the benefits of pulmonary rehabilitation over the longer term.

We studied factors contributing to an increase of DLco (steady state) from rest to exercise in 10 healthy men. DLco(ss), Dm, and Vc were measured under three different conditions, rest, constant load exercise (50 watts), and hyperventilation (equal to the tidal volume and respiratory rate of exercise). DLco(ss) increased significantly during exercise and hyperventilation compared with at rest. DLco(ss) also increased significantly during exercise, compared with hyperventilation. During constant load exercise (50 watts) increased Dm and Vc, caused by increased ventilation, together with increased of Vc caused by increased of pulmonary blood flow resulted in an increase in DLco(ss).

The purpose of this study was to assess the utility of three-dimensional (3D) contrast-enhanced MRI in patients with hemifacial spasm. We performed preoperative MRI in 36 patients in whom microvascular decompression (MVD) was performed and postoperative MRI in 29. All MRI studies were obtained with a 1.5T MRI system using the spoiled GRASS (SPGR) method. In all patients, neurovascular compression of the facial nerve could be detected prior to MVD, and the rate of accuracy was 91.7%. Postoperative 3D-MRI was useful in confirming of displacement of the offending vessels and assessing of its severity.

We sought to clarify the factors associated with exercise capacity in patients with pulmonary emphysema. Exercise capacities of 20 men with pulmonary emphysema were evaluated by bicycle ergometery, and the results were used to divide the subjects into two groups: high exercise capacity (n = 10) and low exercise capacity (n = 10). Pulmonary-function tests were done, emphysema scores were computed from CT scans, breathing pattern was recorded during submaximal exercise (up to 20 watts), and index of rapid shallow breathing was computed. Neither FEV1 nor airway resistance differed between the two groups, and patients with lower exercise capacity tended to have lower tidal volumes and higher values of the index of rapid shallow breathing during submaximal exercise. Functional residual capacity measured by body plethysmography and emphysema scores were inversely associated with exercise capacity. We speculate that among patients with pulmonary emphysema and a given degree of airway obstruction, a high functional residual capacity causes breathing during submaxinal exercise to be rapid and shallow, and that this rapid and shallow breathing makes ventilation inefficient, increases the work of breathing, and limits exercise capacity.

A 55-year-old obese man was admitted to our hospital because of a severe morning headache. He snored and had recurrent episodes of sleep apnea that began 10 years earlier and had since become much worse. An overnight polysomnographic recording confirmed that he had sleep apnea syndrome, predominantly of the central type. The apneas were more frequent when he lay on his back (apnea index 54.5) than on his side (apnea index 1.2). He was treated with sleep position adjustment and nasal bi-level positive airway pressure, inspiratory positive airway pressure at 5 cmH2O and expiratory positive airway pressure at 2 cmH2O. His snoring, headache, and oxygen desaturation resolved. This case suggests that airway collapse may cause central apnea, and that nasal continuous positive airway pressure, and nasal bi-level positive airway pressure and adjustment of sleep position can be effective in some patients with central-type sleep apnea syndrome.

In 14 patients with chronic pulmonary emphysema, the relations between changes in psychological status associated with pulmonary rehabilitation and exercise tolerance were studied with the Cornell Medical Index and the Yatabe-Guiford Personality Inventory. Although the scores on the latter did not change, the cardio-respiratory score on the Cornell Medical Index improved significantly (p < 0.05). The only index of exercise tolerance that improved significantly was the distance walked in 10 minutes (p < 0.05). The changes in the scores of "Lack of Objectivity" and "Rhathymia" correlated negatively with the change in the distance walked in 10 minutes (R = -0.80, p < 0.01; R = -0.81, p < 0.01). The change in psychological status that accompanied pulmonary rehabilitation has been related to the improvement in the distance walked in 10 minutes.

To evaluate the effects of pulmonary rehabilitation on pulmonary function, 15 patients with chronic pulmonary emphysema underwent pulmonary rehabilitation for six weeks as inpatients. Pulmonary rehabilitation consisted of relaxation techniques, breathing retraining, thoracic massage, physical exercise, and walking. In 8 of the 15 patients vital capacity increased by more than 200 ml (over 10%), and in 7 of the 15 patients the load of maximal exercise increased by more than 5 watts (over 10%). Increases in vital capacity were not associated with increases in maximal exercise load. The percent change in vital capacity associated with pulmonary rehabilitation correlated significantly with the percent change in tidal volume and the percent change in expiratory minute ventilation at the maximal load. The percent change in tidal volume at the maximal load correlated significantly with the percent change in maximum oxygen uptake. We attribute the increase in vital capacity to an improvement in thoracic cage movement. These findings suggest that pulmonary rehabilitation can increase vital capacity in some patients with chronic pulmonary emphysema, and that such an increase is not directly connected to increases in exercise capacity.

Mass health screening (MHS) for detecting early cancer of hepatobiliary diseases is not common. However, as high risk factors for developing hepatocellular carcinoma (HCC) has been established in Japan, MHS for HCC is available, especially in high endemic areas of hepatitis C. Intrahepatic bile duct cancer often occur in patients with Thorotrastosis. Cohort study for detection of early cancer of intrahepatic bile duct has been conducting by the Japanese Government. Early detection of bile duct cancer in health screening is very rare. It will be helpful for perform MHS to clarify the high risk factors for bile duct cancers.

Cumulative Fatigue Symptoms Index (CFSI) is used for workers' subjective assessment of feeling of fatigue and of symptoms. Until now, this index has been used in the analysis of members of the same occupation. The purpose of this study is to examine fatigue symptoms in workers and to assess by CFSI the effect of regular physical exercise. Study participants were an exercise group (n = 67) and a non-exercise group (n = 115) of older workers, aged from 30 to 69 years. The CFSI questionnaire was distributed to all participants and the former group (exercise) answered two descriptive questions concerning the aim and subjective effects of physical exercise. As a result, it was found that mental fatigue symptoms decreased in the exercise group even after considering the differences in managerial position, subjective senses on health and marital status which are related to degree of feelings of fatigue. Weakened vitality was significantly less in the exercise group than the non-exercise group. Therefore, we concluded that weakened vitality would be needed to be regarded on an assessment scale for effects caused by exercise. It has also been considered that we should investigate general fatigue in assessing physical fatigue relating to one's lifestyle.

In the present study, we reported a case of the right aortic arch which was found in the course of dissection at Juntendo University in 1993 from a cadaver of a 92-year-old female. The present case possessed as its terminal branch the right subclavian artery. The ascending aorta arose from the left ventricle and ran upwards, curved dorsally and became the right aortic arch. The arch passed on the right side of the trachea and esophagus, curved right posteriorly and became the thoracic aorta which descended on right side of the vertebral column. The aortic arch sent off the left brachiocephalic artery, the right common carotid artery and the right subclavian artery in this order and connected with the pulmonary artery by the right ligamentum arteriosum. The present case represents the 11th report of dissection of a right aortic arch in Japan which was type M according to the classification system of Adachi-Williams-Nakagawa. Type M is subdivided into three subtypes depending on the pattern of the ligamentum arteriosum. The right ligamentum arteriosum has been found in three cases including the present study. We critically discussed previous explanations and theories on the developmental processes of the right aortic arch and its variable major branches and ductus arteriosus.

The intrinsic hand muscles consist of the thenar, hypothenar and midcarpal muscles. Our recent studies on these muscles and their innervation have revealed several new findings which would enhance standard anatomical descriptions of these muscles. 1) R. profundus of the ulnar nerve sends off branches to interossei in order of the spatial arrangement of these muscles. 2) Regarding the thenar muscles, M. opponens pollicis, M. flexor pollicis brevis and M. adductor pollicis form a single mass without clear borders, and their supplying nerves originate from the thenar ansa which is established by anastomosis of one or two branches of the median nerve and a terminal branch of R. profundus of the ulnar nerve. We call this muscle mass the "deep thenar muscle." Due to the lack of definite margins, it is understandable that the anatomical descriptions of the thenar muscles have been so varied. The division of the deep thenar muscle into the three muscles might be regarded as only an artificial division, according to arbitrary criteria.

It has been generally accepted that lung fibrosis as in idiopathic interstitial pneumonia (IIP) is frequently associated with the development of lung cancer. This observation implies that the mechanism involved in carcinogenesis and/or enhanced proliferation of cancer cells is common to the fibrosing process. However, there are few studies reported on the pathogenesis of associated lung cancer except for several studies assessed from the point of view of surgical pathology. This study was undertaken to learn whether BAL fluid, which reflects the local milieu of the fibrosing process, enhances the proliferation of human lung cancer cell line Lu-99, Lu-65 and rat lung fibroblasts as assessed by 3H-thymidine incorporation. BAL fluid was obtained from patients with IIP (n = 8) and normal volunteers (n = 8). BAL fluids from patients with IIP enhanced the mean incorporation of 3H-thymidine of Lu-99 up to 3.6 times (p < 0.01) compared to that of normal volunteers. Furthermore, the mean incorporation of Lu-65 was increased up to 1.8 times (p < 0.05) by BAL fluids from patients with IIP. In contrast, BAL fluids from patients caused no significant increase of the mean incorporation of rat lung fibroblasts as compared to normal BAL fluids. The enhancing activities on the growth of cancer cell line Lu-99, Lu-65 were eluted in several fractions by high performance liquid chromatography using Superose 12. These observations indicate that the BAL fluid of IIP patients contains factors enhancing the growth of cancer cells.

Common respiratory diagnostic imaging techniques using radioisotopes are ventilation-perfusion, perfusion, aerosol inhalation and tumor scintigraphy. The special features of respiratory imaging diagnostic techniques using radioisotopes are the possibility of early detection of disease and the non-invasiveness of the procedure. Also, no patient effort is required. The kinds of isotopes used are as follows: ventilation-perfusion (133Xe, 13N, 99mTc-pseudogas), perfusion (131I, 99mTc), aerosol inhalation (99mTc), tumor (67Ga, 201Tl). The advantages of these procedures are expected to lead to further developments in respiratory examinations using radio isotopes.

The functional residual capacity (FRC) has been measured by gas dilution technique (GA) and body plethysmographic technique (BP) using the panting maneuver (PA). However, this maneuver is difficult to perform for patients who experience discomfort in breathing, and in cases of chronic obstructive pulmonary diseases, the FRC value measured by panting maneuver overestimates the true FRC value. Thus, in order to minimize these factors, we measured FRC during non-panting breathing (NP) using a BP device (BX-82, Minato Co., Osaka) and compared the results with the usual two methods. One hundred healthy subjects (Group I), 72 patients with restrictive ventilatory disorder (Group II, %VC = 62.7%) and 66 patients with pulmonary emphysema (Group III, FEV1.0% = 44.9%) were studied. All measurements were performed under 0.5 Hz respiratory frequency. The non-panting FRC measurement was performed by closing the mouth shutter of the BP for about 500 msec at the end of both the expiratory and inspiratory phase. From the box volume change and mouth pressure change, lisajous curves were formed and fitted by linear regression method. From this regression line, the volume of FRC was calculated. The obtained data had no significant differences among them, and there was a significant relationship between each technique. The correlation coefficient of non-panting breathing technique in Group III was slightly poor compared with the other techniques, and we therefore tried to re-classify Group III into small groups according to the severity of obstruction. It was subsequently found that this technique did not have the tendency to give a higher FRC value with increase in obstructive disorder.(ABSTRACT TRUNCATED AT 250 WORDS)

Various renal tubular functions were monitored perioperatively in 42 surgical patients and the validity of beta-2-microglobulin (BMG) was evaluated. NAG index (urine NAG titer/urine creatinine), the absolute value of free water clearance and fractional excretion of sodium were worse at 3 to 5 hours after the beginning of operation, indicating the latent renal tubular damage took place during operation. On the other hand, fractional excretion of BMG (FE-BMG; BMG clearance/creatinine clearance) slowly elevated after operation and reached a peak on the 2nd postoperative day. The postoperative change of C-reactive protein (CRP), was similar with that of FE-BMG, showing a significant correlation (r = 0.716, p less than 0.001). The close relationship between CRP and FE BMG was confirmed in 26 patients with or without abnormal liver function who underwent abdominal operation. The peak value of FE BMG was significantly (p less than 0.01) lower in 5 patients with ICG 15' greater than 25% than in 21 patients with ICG 15' less than 20%. Similarly, the peak value of CRP tended to be lower in the former group. In conclusion, FE BMG can not be employed as an indicator of renal tubular function during postoperative period. It reacts as an acute phase reactant like CRP and is probably produced in the liver.

The Ag-NORs technique, staining nucleolar organizer regions, was performed on 23 areas of colonic normal mucosa, 17 adenomas with low grade atypical and 8 adenocarcinoma invading submucosa, to examine its possibility of application to the pathological diagnosis of colonic epithelial neoplasia. In normal colonic gland, the average number of Ag-NORs per 1 nucleus in cells of lower two-thirds showed significantly higher value (p less than 0.01) than higher one-third, and the mean cross-section area per 1 Ag-NOR in lower two-thirds showed a tendency to be larger than higher one-third. This results suggested that there was a positive correlation between the proliferative activity of cells and the number and size of Ag-NORs. A comparison of normal gland, adenoma and adenocarcinoma showed that the mean cross-section area of Ag-NORs correlated positively to their histological grade of atypia, but the average number did not. However using these two parameters, these three lesions had a tendency to be discriminated respectively at the average Ag-NORs number of 2.8 dots and the area of 2 microns. These results suggested that the Ag-NORs technique was expected to be a useful method for histopathological diagnosis of colonic epithelial neoplasia.

To investigate the possibility that to detect carcinoma of the pancreas at an early stage by mass survey or outpatients screening, we performed the multicentral study for pancreatic cancer in Japan for two years from 1984 to 1985, using serum CA 19-9 and elastase-1 determinations or ultrasonography. Only 4 cases of pancreatic cancer were found out by mass survey, and according to outpatients screening with gastrointestinal complaints or jaundice, 85 patients were found to have pancreatic cancer. These results suggest that mass screening of persons without symptom is not worthy of the early detection of pancreatic cancer, however, outpatients screening gis useful for detecting curative cancers of the pancreas.

Some patients with spinal cord injury complain of a severe intractable pain. This intractable pain places new hurdles on the road to return to the ordinary daily life in these patients. The effective therapy for the intractable pain has not been established. Dorsal root entry zone (DREZ) lesion was originally reported by Nashold et al to alleviate deafferented pain syndrome. Three male and one female patients with intractable pain following spinal cord injury were treated with DREZ-lesions. One month after operation, all 4 patients obtained good pain relief. However, at a follow-up period till February 1989 (ranging 11 months from 2 years and 6 months), 2 patients had subjective pain relief. When other therapies on intractable pain following spinal cord trauma are not effective, the DREZ-lesion might be considered.

Tetracycline has been used for the local treatment of malignant pleurisy ever since of Robinson (1972) reported its effectiveness. In this report, we try to elucidate possible mechanisms of action of this drug from the viewpoints of (1) pharmacokinetic analysis following intrapleural administration, and (2) pleural reaction. The results were as follows: (1) In 5 patients with malignant pleural effusion, 500 mg of doxycycline was injected into the pleural cavity and pharmacokinetic analysis was performed. The clearance curve of doxycycline in pleural fluid was described by either a one-compartment model or a two-compartment model. The mean half life of slow space was 33.3 hr, which suggested delayed excretion of this drug from pleural space. (2) The direct effect of doxycycline on pleura was studied in rabbits. At a dose of 10 mg per kg of body weight, the mesothelial cells became cuboid and contained vacuoles in their cytoplasma. With increasing dose up to 40 mg per kg, the changes in mesothelial cells were enhanced. In submesothelial tissue, edema and cellular infiltration were noticed. Three weeks later, normalization of mesothelium was observed, being followed by connective tissue proliferation. These findings may support the efficacy of tetracycline for local treatment of malignant pleurisy.

Pancreatic oncofetal antigen (POA) was purified from fetal pancreas and migrated in beta-region electrophoretically. Its molecular weight was 80 X 10(4) daltons. Enzyme immunoassay for serum POA revealed that elevated levels of POA were found in sera of patients with pancreatic cancer. By a serological screening of 440 out-patients with combined assay of tumor markers including POA, 4 cases of pancreatic cancer were found. POA was demonstrated in the ductal cells of fetal pancreas and cancer cells of duct cell type pancreatic adenocarcinoma immunohistochemically. Elevated levels of serum POA of patients with pancreatic cancer was probably derived from cancer tissue. These findings indicate that serum POA assay is clinically useful.