Search

Recently, a novel quantitative method using relative molar sensitivity (RMS) was applied to quantify the ingredients of drugs and foods. An important development in this regard can be observed in the Japanese Pharmacopoeia (JP) 18, where the quantification of perillaldehyde, an unstable compound, in crude drug "Perilla Herb," was revised to incorporate the RMS method. In this study, the primary objective was to improve the tester safety and reduce the amount of reagents used in the JP test. To achieve this, the quantification of three toxic Aconitum monoester alkaloids (AMAs) was explored using the RMS method, employing a single reference compound for all three targets. These AMAs, namely benzoylmesaconine hydrochloride, benzoylhypaconine hydrochloride, and 14-anisoylaconine hydrochloride, which are the quantitative compounds of Kampo extracts containing Aconite Root (AR), were quantified using the reference compound benzoic acid (BA). Reliable RMS values were obtained using both 1 H-quantitative NMR and HPLC/UV. Using the RMS of three AMAs relative to the BA, the AMA content (%) in commercial AMAs quantitative reagents were determined without analytical standards. Moreover, the quantitative values of AMAs using the RMS method and the calibration curve method using the three analytical standards were similar. Additionally, similar values were achieved for the three AMAs in the Kampo extracts containing AR using the RMS and the modified JP18 calibration curve methods. These results suggest that the RMS method is suitable for quantitative assays of the Kampo extracts containing AR and can serve as an alternative to the current method specified in the JP18.

A 73-year-old man developed delayed-onset multiple cranial neuropathies of cranial nerves V, VII and VIII, and segmental paresis in the ipsilateral upper extremity related to the C4 to Th1 segment, after all skin lesions with varicella zoster (VZV) on the left neck of the C3-4 dermatome had dried and crusted over. On admission, cerebrospinal fluid (CSF) revealed pleocytosis (all mononuclear cells, 12/μl). Treatment was started with intravenous acyclovir (10 mg/kg, every 8 h for 14 days) and methylprednisolone (1,000 mg/day for 3 days). Four days after starting treatment, left segmental paresis was improved, but the multiple cranial neuropathies persisted. Oral prednisolone (0.5 mg/kg/day) was administered for 5 days, then tapered off. All neurological symptoms had disappeared by hospital day 23. Of particular interest was the discrepancy between skin regions affected by VZV (C3-4) and the regions of cranial neuropathy (cranial nerves V, VII, and VIII) and muscle weakness innervated by C4-Th1. Although CSF was negative for VZV DNA according to PCR testing, the antibody index for VZV was elevated. This suggests intrathecal synthesis of VZV antibodies and supports the diagnosis of VZV meningitis. Also, all cranial nerves involved in this case were reported to have the cranial nerve ganglia where VZV could have established latency and been reactivated. This suggests concurrent reactivation on each cranial nerve ganglia without cutaneous lesions, as zoster sine herpete. In addition, anastomoses among the upper cervical nerves, which are found in some patients, may have contributed to this condition. These mechanisms underlie various neurological symptoms associated with VZV infection.

A 60-year-old man developed aphasia and transient right upper limb paresis in the presence of chronic subdural hematoma and was transferred to our hospital at an early stage. Cranial MRI within an hour after onset showed diffusion-weighted image (DWI) hyperintensity in the left parietal, temporal, and insular cortex and the pulvinar, and decreased apparent diffusion coefficient (ADC) in the left parietal cortex and pulvinar, suggesting a differential diagnosis of hyper-acute ischemic stroke. However, the distribution and timing of the MRI abnormalities were considered to be atypical for hyper-acute ischemic stroke. The area with both DWI hyperintensity and decreased ADC included the cerebral cortex adjacent to the hematoma and the ipsilateral pulvinar, and fluid-attenuated inversion recovery (FLAIR) hyperintensity co-existed with DWI hyperintensity within only an hour from onset. Furthermore, FLAIR images showed infiltration of the hematoma content into the subarachnoid space, which might have triggered the attack. These findings collectively led us to diagnose an epileptic seizure. The present case suggests that the distribution and timing of MRI abnormalities are essential to differentiate epileptic seizures from hyper-acute ischemic stroke.

Unresectable advanced gastric cancer is associated with poor prognosis. In a few studies, long-term survival was achieved with conversion surgery in patients who responded to chemotherapy. Here, we have reported a case of unresectable advanced gastric cancer in which curative resection was achieved with conversion surgery. A 70-year-old man who was diagnosed with advanced gastric cancer with multiple liver metastases received S-1/cisplatin therapy(S-1 120 mg/kg of bodyweight[bw]plus cisplatin 90 mg/kg of bw)as primary therapy. Because of the adverse reactions, secondary treatment with irinotecan therapy(CPT-11 200 mg/kg of bw)was initiated, which led to clinical complete response. A local recurrence was observed 44 months later; hence, irinotecan therapy was reinitiated. Although the disease was stable for 30 months, disseminated nodules appeared; thus, immunotherapy(nivolumab 150 mg/kg of bw)was initiated as tertiary treatment for the progressive disease. Although the number of disseminated nodules decreased, frequent blood infusions were necessary for anemia. Distal gastrectomy was planned as palliative surgery. Since no noncurative factors were detected intraoperatively, we considered that curative resection could be achieved with pancreaticoduodenectomy and changed the procedure. The operative time was 6 hours 35 minutes, and there was a blood loss of 312 g. The pathological diagnosis was ypT2- N1M0P0M0, ypStage ⅡA. At 13 months postoperatively, the patient was alive without recurrence.

Metastases to the subcutaneous scrotum are extremely rare. Here, we report a 78-year-old man who presented with pain to the scrotum and inguinal area. Two years ago, he underwent total gastrectomy for gastric cancer. The pain was attributed to increased scrotal wall thickness. Incisional biopsy of the thickened scrotal wall revealed diffused infiltration of the subcutaneous tissue by islands of scirrhous type malignant cells. Moreover, immunohistochemical studies showed that the tumor cells were positive for CK7, CK20, and CDX-2. These features suggested a metastatic adenocarcinoma of upper gastrointestinal origin. Although there were no visceral metastases, the tumor cells were too widely spread to be dissected curatively. Palliative chemotherapy with tegafur, gimeracil, and oteracil (S-1) was restarted, and local pain was subsequently ameliorated. Since scrotal metastasis is unlikely to occur it is difficult to diagnose. Therefore, in patients with groin discomfort or swelling and a history of gastric cancer, metastatic adenocarcinoma should be included in the differential diagnosis for early detection of a tumor.

A man in his 80s was admitted to our hospital with a chief complaint of bloody stools. He was diagnosed with cT2N0M0, cStage Ⅰ rectal cancer. As the patient was of advanced age and had multiple comorbidities, definitive chemoradiotherapy was administered. Immediately after treatment, the patient achieved a complete clinical response, and recurrence has not been detected for 2 years and 3 months since treatment.

Quantitative NMR (qNMR) has been developed as an absolute quantitation method to determine the purity or content of organic compounds including marker compounds in crude drugs. The "qNMR test" has been introduced into the crude-drug section of the Japanese Pharmacopoeia (JP) for determining the purity of reagents used for the assay in the JP. In Supplement II to the JP 17th edition published in June 2019, fifteen compounds adopted qNMR test were listed as the reagents for the assay. To establish the "qNMR test" in the crude drug section of the JP, there were several problems to be solved. Previously, we reported that the handling impurity signals from reference substances and targeted marker compounds, chemical shifts of reference substances, and peak unity of signals of targeted marker compounds are important factors to conduct qNMR measurements with intended accuracy. In this study, we investigated that the hygroscopicity of reagents could cause the changes in the compounds' purity depending on increasing their water content. Twenty-one standard products used for the crude-drug test in JP were examined by water sorption-desorption analysis, and ginsenosides and saikosaponins were found to be hygroscopic. To prepare a sample solution of saikosaponin b 2 for qNMR analysis, samples need to be maintained for 18 h at 25°C and 76% relative humidity; further, samples need to be weighed at the same humidity for the qNMR analysis.

A 52-year-old man underwent upper gastrointestinal endoscopy screening that identified a submucosal tumor in the gastric fornix, and a solid tumor with a maximum diameter of 35mm was suspected based on abdominal computed tomography. An endoscopic ultrasound-guided fine needle aspiration biopsy showed spindle-shaped cells with KIT, CD34, desmin, and S-100 all testing negative. Based on the diagnosis of a gastrointestinal stromal tumor, subtotal gastrectomy was performed laparoscopically. Postsurgical histopathological testing led to a diagnosis of a primary gastric inflammatory myofibroblastic tumor. The present case has been defined as one involving a tumor part way along the spectrum between benign and malignant, with local recurrence and distal metastasis. Reports indicate that recurrence occurs frequently in cases wherein sufficient margins are not obtained or wherein there is enucleation, and complete surgical resection is recommended. With laparoscopic surgery, because an enlarged field of view can be obtained, and depending on the lesion site, good exposure of the operative field is possible, the authors believe that this approach would be beneficial in terms of local control. Moreover, it has been reported that anaplastic lymphoma kinase(ALK), which is a tyrosine kinase receptor protein, tests positive in approximately 60% of cases. Reports have also indicated that distal metastasis occurs frequently in cases in which ALK tests negative, and watchful waiting of these cases at regular intervals should be carried out to the same extent as of cases involving malignant tumors.

An 85-year-old male patient was referred to our hospital for further examination of a liver tumor. Imaging examination revealed a 90-mm tumor in segment 4/8 and 30-mm tumor in segment 6 of the liver. Histopathological examination revealed that the tumor in segment 4/8 was cholangiolocellular carcinoma (CLC) and the tumor in segment 6 was hepatocellular carcinoma (HCC). This case shows that although the frequency of CLC is very low, recent studies have indicated the novel knowledge of CLC. Herein, we report a surgical case of CLC and HCC in the background of resolved hepatitis B virus infection.

Omentoplasty has been accepted as an effective surgical procedure for fistulated empyema. However, it is difficult for patients with poor nutritional status because their omental volume is often too poor to be applied for omentoplasty. Percutaneous endoscopic gastrostomy(PEG) is useful for long-term nutritional management. There is no report on safety and usefulness of PEG before omentoplasty. We report a case of omentoplasty that was successfully performed after nutritional enforcement by using percutaneous endoscopic gastrostomy in a patient of postoperative empyema with fistula.

Morphine with its potent analgesic property has been widely used for the treatment of various types of pain. However, the intrathecal (i.t.) administration of morphine at doses far higher than those required for antinociception exhibited nociceptive-related behaviors consisting of scratching, biting and licking, hyperalgesia, and allodynia in mice. Morphine-3-glucuronide (M3G), one of the major metabolites of morphine, has been found to evoke nociceptive behaviors similar to those after high-dose i.t. morphine. It is plausible that M3G may be responsible for nociception seen after high-dose i.t. morphine treatment. This article reviews the potential mechanism of spinally mediated nociceptive behaviors evoked by i.t. M3G in mice. We discuss the possible presynaptic release of nociceptive neurotransmitters/neuromodulators such as substance P, glutamate, dynorphin, and Leu-enkephalin in the primary afferent fibers following i.t. M3G administration. It is possible to speculate that i.t. M3G could indirectly activate NK1, NMDA, and δ2-opioid receptors that lead to the release of nitric oxide (NO) in the dorsal spinal cord. The major function of NO is the production of cGMP and the activation of protein kinase G (PKG). The NO-cGMP-PKG pathway plays an important role in M3G-induced nociceptive behavior. The phosphorylation of extracellular signal-related kinase (ERK) in the dorsal spinal cord was also evoked via the NO-cGMP-PKG pathway through the activation of δ2-opioid, NK1, and NMDA receptors, contributing to M3G-induced nociceptive behaviors. The demonstration of a neural mechanism underlying M3G-induced nociception provides a pharmacological basis for improved pain management with morphine at high doses.

A 71-year-old man was diagnosed with a gastric tumor approximately 50mm in diameter on computed tomography (CT). In January 2000, he underwent a proximal gastrectomy. Pathological examination showed 5 mitoses per 50 high-power fields, while immunohistochemical analysis showed positive staining for KIT. Accordingly, the tumor was diagnosed as an intermediate- risk malignant gastrointestinal stromal tumor (GIST) for which the patient was followed. In January 2002, an abdominal CT scan revealed multiple hepatic tumors and a lower abdominal tumor, and the patient was diagnosed with liver metastases and peritoneal disseminations from GIST. After informed consent was provided, chemotherapy with 400 mg/day imatinib was initiated. The patient demonstrated a partial response 2 months after treatment. At 12 years 8 months after the diagnosis of liver metastasis and peritoneal disseminations, the patient shows no sign of recurrence.

A 73-year-old woman was admitted with severe burning pain, hyperesthesia, and weakness in the right lower extremity. The patient had undergone radio- and chemotherapy after surgery for cervical cancer 17 years earlier. We diagnosed radiation-induced lumbosacral plexopathy because of conduction block in the deep peroneal nerve and myokymic discharge in the tibialis anterior muscle. Pelvic computed tomography and magnetic resonance imaging ruled out recurrent tumor and nerve-compressing lesions. Although radiation-induced lumbosacral plexopathy is usually characterized by lower motor neuron syndrome, we report a rare case presenting with severe pain and hyperesthesia.

A 64-year-old woman underwent cholecystectomy for treatment of cholecystolithiasis in January 2005. Pathological examination rendered a diagnosis of gallbladder carcinoma. Wedge resection of the liver and dissection of the lymph nodes was performed. No tumor cells in either the liver nodule or lymph nodes were found during pathological examination. At 4 years after surgery, paraaortic lymph node recurrence was confirmed by computed tomography (CT). Gemcitabine was administered once weekly for the first 3 weeks in a monthly cycle, but the tumor continued to increase in size. Gemcitabine was then switched to TS-1, after which it was changed to cisplatin because of continued tumor growth. After 35 courses of chemotherapy, CT showed the disappearance of the paraaortic lymph node, and the patient achieved a complete response. She is currently free of disease at 9 years after surgery.

A 74-year-old woman underwent distal gastrectomy and D1+ α dissection for the treatment of gastric cancer (pT2a, pN2, H0, P0, M0, Stage IIIA) in February 2008. She was treated with adjuvant postoperative chemotherapy consisting of TS-1. However, 32 months after the operation, paraaortic lymph node recurrence was confirmed by computed tomography (CT). She was treated with combined TS-1 and cisplatin chemotherapy. After 14 courses, CT revealed that the paraaortic lymph node metastasis had disappeared, and a complete response was attained. The patient is currently disease-free, 6 years after the operation.

We describe a case with mycotic aneurysm in a descending thoracic aorta. We applied thoracic endovascular aortic repair (TEVAR) technique to that aortic aneurysm after administering the high dose antibiotics and controlling the infection. Postoperative course was uneventful and he was in a good condition.

A 62-year-old man was admitted to a local hospital for cervical abscess. He was given an antibiotic, but his symptoms worsened. Computed tomographic cervical and chest scan 6 days after hospitalization revealed that left cervical abscess extended to the mediastinum. He was transferred to our hospital following a diagnosis of descending necrotizing mediastinitis. Cervical and left transthoracic drainage through a left cervical incision and a left antero-axillary thoracotomy were performed on hospital day 1. On hospital day 2, chest radiograph revealed enlargement of the superior mediastinal shadow. Mediastinoscopic drainage was performed for the abscess in the paratracheal space on hospital day 3. Two mediastinal drainage tubes were placed in the upper and middle mediastinal space using mediastioscopy. Postoperatively, he required additional right transthoracic drainage by chest tube for pleural effusion on hospital day 5. Then his clinical and radiological findings gradually improved, and he was discharged from hospital day 37.

Aim: The purpose of this study was to examine the effects of bright light exposure on behavioral and psychological symptoms of dementia (BPSD), including sleep disturbances and the burden on caregivers in institutionalized elderly with cognitive decline., Methods: The subjects included eight people with cognitive decline (mean [SD] age, 79.9 [9.1] years) living in geriatric healthcare facilities for the elderly. BPSD and the burden on caregivers were measured over three weeks using the CMAI (Cohen-Mansfield Agitation Inventory), NPI-NH (Neuropsychiatric Inventory-Nursing Home Version) and J-ZBI (Modified Japanese Version of the Zarit Caregiver Burden Interview) at the end of each week. During the second week, the subjects received either 12,000 K (white) or 2,400 K (orange) of light corresponding to approximately 2,000 lux from a light-emitting diode (LED) device, measured before the eyes in the gaze direction, from 9 : 00 to 9 : 30 during occupational tasks, such as origami and coloring. Differences in the variables obtained at the different weeks were assessed using ANOVA with multiple comparisons., Results: The scores for the severity of BPSD, including sleep disturbances and the burden on caregivers, on the NPI-NH significantly (P<0.05) improved following the treatment with white light exposure, while the scores for the MMSE and J-ZBI did not change over the three-week study period., Conclusions: These results suggest that exposure to white bright light during occupational tasks in the morning may have a benefit in improving BPSD, including sleep disturbances and the burden on caregivers.

Pharmaconutrition, which is a supportive nutritional care of surgical patients, has been proven to shorten hospital stay, decrease the incidence of infection, and reduce hospital costs in selected groups of patients. Arginine, one of the most essential pharmaconutrients, has also been proven to enhance would healing process. In severely malnourished patients like bronchopleural fistula with resultant empyema, aggressive nutritional approach should be mandatory. And management of the fistula is also important in stabilizing the ongoing infection. Our hypothesis was that basic nutritional support enhanced with arginine would be effective in not only improving the general condition including nutritional status but also in healing the fistula. We report a case of major bronchopleural fistula in which arginine-supplemented diet as well as aggressive nutritional support could accelerate the postoperative recovery after open thoracic window, ultimately leading to the healing of the fistula.

The fall risk has 3.6 fold in Dementia with Lewy Bodies (DLB) and 16 fold post faller syndrome among diseases to cause dementia, and it was reported that have a significant parkinsonism and a fall more. DLB has multiple symptoms such as that physical symptom, rather than worsening a symptom by characteristics of high sensibility medical intervention for medication, and has severe problem falls. It was indicated that make a decrease a fall risk for restored cognitive function with executive function in the elderly peoples. Thus, improve the quality of care and the establishment of non - pharmacological therapies, for it is important to further therapeutic exercise as prevention is required cooperation and sharing information across professions.

We report two cases of adult T-cell leukemia/lymphoma(ATLL)having their main lesions in the stomach. Case 1 was a 74-year-old man, complaining of left upper abdominal mass and pain. Upper gastrointestinal endoscopy revealed an ulcerous lesion in the stomach. Histological analysis and southern blotting for HTLV-1 pro-viral DNA led us to our diagnosis of ATLL. There were no apparent lesions in the bone marrow and other organs. He died of tumor lysis and multi-organ failure shortly after treatment with the VCAP-AMP-VECP regimen. Case 2 was a 68-year-old man complaining of abdominal bloating and pain. Upper gastrointestinal endoscopy disclosed an irregularity of the gastric mucosa. A biopsy sample was diagnosed pathohistologically as non-Hodgkin's lymphoma. We conducted total gastrectomy. Based on the results from the histological study and southern blotting for HTLV-1 p ro-viral DNA in the resected specimen, a diagnosis of ATLL was made. We treated him with a VCAP-AMP-VECP regimen, but multiple bone metastases and pathologic fracture occurred, proving that the disease was progressive. ATLL having a main lesion in the stomach is rare, and requires an accumulation of cases analyzed with careful diagnostic approach to establish a standard therapy for it.

Immunonutrition, which is a therapeutic approach to modulate acute surgical or medical conditions, has been proven to decrease surgical site complications in patients undergoing major elective surgery for upper gastrointestinal and esophageal malignancy. For immunonutrition to be carried out effectively, specific nutrients called pharmaconutrients are quite important. In our case, to enhance the perioperative nutritional status of the patient, special formulas supplemented with specific pharmaconutrients, which are arginine and omega-3 fatty acids, were orally administered. The open thoracic window for chronic empyema caused by postoperative bronchopleural fistula was successfully closed. Perioperative immunonutrition is likely to have beneficial effect in decreasing postoperative infectious complications in high-risk malnourished thoracic surgical patients.

A 38-year-old woman visited our hospital complaining of decreased appetite and sensation of pressure on her abdomen. Computed tomographic scan revealed right giant renal angiomyolipoma. Partial nephrectomy was performed. The resected specimen weighed 970 grams. The histological diagnosis was consistent with angiomyolipoma. Partial nephrectomy was performed because the connection between the tumor and the kidney was in a small range and the tumor was detached easily from the surrounding tissue.

Because of the refractory and recurrent nature of febrile neutropenia (FN), definite diagnosis and early empiric treatment with antibiotics are important for FN patients. With this background, guidelines for FN treatment have been published in Japan and overseas, although a treatment method appropriate for clinical practice in Japan has not yet been established. Therefore, we conducted a survey of actual practice, including trends in prescription of antibiotics for FN, in the hope that it would help establish a definitive treatment for FN in Japan. The survey results confirmed that FN patients under care of hematology departments accounted for the largest proportion, followed by pediatrics (hematology), pulmonary medicine, medical oncology, and respiratory surgery, and the proportions of patients diagnosed with FN and those receiving antibiotics in hematology departments are larger than in other departments. Across all departments, cefepime (CFPM) is most frequently used as the initial treatment of choice, accounting for 35.9% of prescriptions, followed by meropenem (MEPM) (24.3%). These drugs are selected because they exhibit high potency and wide coverage against organisms that are presumed to cause FN, and their costs are covered by insurance, while the existence of insurance coverage is the major determining factor for treatment in Japan. Among second-line drugs, MEPM is most frequently used, accounting for 46.3% of prescriptions. The guidelines are commonly used as the basis for treatment, accounting for 52.0% of all departments, especially the guidelines established by the Japan Febrile Neutropenia Study Group. On the other hand, the percentage of departments that have introduced a hospital protocol and clinical path is only 13.0% in total. To provide appropriate treatment for FN patients, insurance coverage and introduction of a hospital protocol and clinical path based on guidelines and evidence are essential. The current situation, in which these are not implemented, is not desirable. The survey results show that the guidelines need to be revised to more closely reflect the actual situation in Japan and hospital protocols and clinical paths need to be introduced.

A 79-year-old female who had been observed for an intrapericardial cyst for 3 years was admitted due to severe dyspnea and back pain. During 3 years observation, there were no symptoms and no growth of the cyst. Computed tomography scans showed rapid expansion of the cyst compared with an magnetic resonance imaging (MRI) taken 9-days before when she visited our hospital for the 1st time. Urgent complete extirpation of the tumor was successfully done and a histological diagnosis found it was an intrapericardial bronchogenic cyst. This is a 1st report of intrapericardial bronchogenic cyst of which rapid expansion is clearly demonstrated by radiology. It is suggested that complete surgical excision of intrapericardial bronchogenic cysts at the time of diagnosis even if asymptomatic.

Febrile neutropenia (FN) is a serious complication associated with morbidity and mortality. To manage infections in neutropenic patients, it is necessary to administer empirical antibiotic therapy in a timely and efficient manner. We developed an electronic critical pathway system for a computer-stored medical record system (EGMAIN-GX, Fujitsu), which matches FN patients to either: i) the first-line therapy with meropenem (3 g/day) alone, or ii) the second-line therapy with meropenem plus vancomycin (2 g/day). If patients do not respond to the first-line therapy within 72 hours, then they are provided with the second-line therapy. A total of 28 FN events were treated in 14 patients presenting with hematological malignancies. The mean and median neutrophil counts were 42 (0-300)/microl and 0/microl, respectively. The response rates with the first-line and second-line therapies were 57% and 93%, respectively. There were no serious adverse events. Meropenem is a highly effective treatment for FN. Use of an electronic critical pathway system could ensure that neutropenic patients receive this necessary empiric therapy in a timely manner so as to prevent the serious complications associated with FN.

Background: Peripheral nerve block (PNB) is now widely performed in operating room by anesthesiologists. PNB is associated with multiple benefits compared to general anesthesia, but we should consider the complications of PNB., Methods: Case reports about complications related to PNB are reviewed. Case reports related to neuraxial blocks and ophthalmologic blocks are excluded., Results: 115 case reports are included. There are most reports related to the interscalene brachial plexus block when it was classified in the category of block, and most reports are related to neuropathy in terms of complications. There are only 3 reports in which ultrasound guided PNB is performed., Conclusions: Ultrasound guided PNB has become very popular now, and it has many potential advantages, such as direct visualization of nerves and anatomical structures, and direct and indirect visualization of spread of local anesthetics during injection with the possibility of repositioning the needle in case of maldistribution of local anesthetic. The half of these complications can be prevented by use of ultrasound guided PNB.

The patient was a 30-year-old man who had undergone living-donor kidney transplantation for renal failure caused by IgA nephropathy at age 29. On post-transplantation day 83, he visited our department with a chief complaint of asymptomatic hematuria. CT performed on post-transplantation day 95 revealed a tumor (size, 4 cm) in the right native kidney that had not been observed at the time of transplantation. CT performed on post-transplantation day 153 showed that the tumor had enlarged to 6 cm, while retrograde pyelogram performed on post-transplantation day 171 was negative for renal pelvic tumor. On post-transplantation day 193, radical right nephrectomy was performed. The tumor had directly invaded the diaphragm and the lower surface of the liver, and was histopathologically diagnosed as rhabdoid tumor of the kidney. As the pathological tissue was extremely malignant, hepatic posterior segmentectomy, right adrenalectomy, and lymph node dissection were further performed for metastases on post-transplantation day 200. On the 23rd day after radical right nephrectomy (post-transplantation day 216), the patient developed dyspnea. Chest CT showed pleural effusion, hemothorax in right lung and metastases in both lungs. The patient's general status gradually worsened thereafter, and he died on the 53rd day after radical right nephrectomy (post-transplantation day 246). Rhabdoid tumor of the kidney is a rare renal tumor that affects children, and only four adult cases have been reported to date. We report our experience with this rare case.

Liposomal amphotericin B (L-AMB), a lipid-based amphotericin B formulation, has been used in Japan since June 2006 to treat fungal infection. In the 3 years since L-AMB was launched, few reports have been made on its status. To ensure its appropriate use, we restrospectively reviewed its efficacy and safety in treating fungal infections. 25 subjects with fungal infection treated with L-AMB from April 2007 until February 2008. Of those, 16 showed clinical improvement. Elevated serum creatinine occurred in 1 and decreased serum potassium in 6. We found a positive relationship between the serum potassium decrease and L-AMB dose. Logistic regression analysis of this relationship showed that serum potassium tended to fall on day 5 to 6 of L-AMB administration. While L-AMB appears highly effective in fungal infection, it requires serum potassium monitoring to ensure patient safety.

As ultrasound beam does not penetrate the air, it has long been thought that ultrasound imaging is not useful for evaluation of the pulmonary parenchyma. However, recent studies have shown that the artifact pattern generated by the lung can be used for the diagnosis of acute respiratory failure. Lung ultrasonography can provide us important informations inside the lung in a real-time fashion. Furthermore, general application of extended ultrasonography would be of greater benefit for perioperative diagnosis and intervention.

A 78-year-old man had non-small cell lung cancer (NSCLC) in the left upper lobe (squamous cell carcinoma, cT1N0M0). He preferred less invasive treatment and undertook stereotactic radiotherapy (SRT)[48 Gy/4 Fr] because his forced expiratory volume in 1 second percent (FEV1.0%) was 53.50%. The therapeutic effect was partial response and the adverse reaction was dermatitis (grade 1). Seven months after SRT, local recurrence was detected. The tumor was growing from 3 x 5 mm to 25 x 25 mm in size. Nine months after SRT, left upper lobectomy was performed successfully unaffected by SRT. He is doing well 14 months after the operation without any signs of recurrence. This case might help develop a new strategy for the treatment of stage I NSCLC. It is that patients with stage I NSCLC have SRT as 1st line treatment, and if local recurrence is observed after SRT, lobectomy may be performed.

Heart rate variability (HRV) is a measure of the beat-to-beat variations in heart rate. It is usually calculated by analyzing a time series of beat-to-beat intervals from the ECG. Various measures of heart rate variability have been proposed, which can be subdivided into time domain, frequency domain and non-linear measures. HRV is regarded as an indicator of the activity of autonomic regulation of circulatory function. HRV has considerable potential to assess the role of autonomic nervous system fluctuations in normal healthy individuals, in patients with various cardiovascular and noncardiovascular disorders and, in patients undergoing general anesthesia. HRV studies should enhance our understanding of physiological phenomena, perioperative cardiovascular changes, the actions of medications, and disease mechanisms.

Malignant sertoli cell tumor is a rare disease and only a few cases have been described previously. We report a terminal case of malignant sertoli cell tumor. A 38-year-old male visited a hospital with a complaint of swelling his left testis. He underwent high left orchiectomy. His pathologic diagnosis was suspected seminoma, and all tumor markers (LDH, HCG, AFP) were negative, and CT imaging confirmed clinical stage 1 (pT1N0M0S0). One year later, a CT scan showed a small retroperitoneum lymph node swelling. Four months later, these lesions increased to 55 x 45 x 70 mm in diameter. He received 3 courses of chemotherapy with BEP (bleomycine, etoposide, cisplatin), but, lymph node size did not change. After he underwent a CT guided lymph node biopsy, his pathologic diagnosis was viable embryonal carcinoma. He then came to our hospital. We selected CPT-11 and nedaplatin for his salvage chemotherapy, but lymph node lesions did not change. After he received 3 courses of chemotherapy, we performed retroperitoneal lymphadenectomy. His pathologic diagnosis was viable sertoli cell tumor, malignant type. After 30 days, he had multiple liver metastases ane died 27 months after orchiectomy. All tumor markers were negative in his all clinical courses.

Femoral nerve block is well suited for surgery on the anterior aspect of the thigh and knee. The primary indication of continuous femoral nerve block is pain management after major femoral or knee surgery. Ultrasound image guidance for femoral nerve block can improve block success rate and decrease complications. We describe the ultrasound scanning, needling technique, and catheter insertion technique for single-dose technique and continuous infusion technique.

Ultrasound-guided peripheral nerve block has been gaining popularity in the community of anesthesiologists. Despite its well-known clinical benefits, inconsistent success in block has been one of the major limita- tions of conventional peripheral nerve block. Recent development in ultrasound technology enables us to see nerves, needles and surrounding structures in real-time. We expect that ultrasound imaging may overcome the shortcoming of conventional technique. In this article, we introduce some evidences that support the clinical benefits of ultrasound-guided peripheral nerve block, including performance time, quality, onset and duration of sensory blockade, cost analysis and patient satisfaction. However, ultrasound-guidance may be even more dangerous without appropriate imaging of target nerve and surrounding structures, accurate localization of needle tip and assessment of local anesthetic spread around the target nerve. These problems will be solved by future guidelines, teaching program and further advancement in ultrasound technology.

Strain voiding has been reported to be a frequent symptom following radical prostatectomy. However, pathophysiology of vesicourethral function underlying voiding difficulty has not been well studied. In the present study, we investigated detrusor underactivity following radical prostatectomy. The records on urodynamic study (pressure-flow study, urethral pressure profile) were retrospectively investigated in 80 patients undergoing laparoscopic radical prostatectomy and all urodynamic studies pre- and post-operatively. We extracted the cases with detrusor underactivity according to the criteria of overt strain voiding pattern on post-operative pressure flow study; detrusor pressure at the maximum flow rate (Pdet Q(max)) of less than 10 cmH2O in conjunction with an increase of abdominal pressure. Of the 80 patients, 6 (7.5%) were found to have detrusor underactivity. In all patients, good detrusor contraction was confirmed on the pre-operative urodynamic study performed before surgery. On the voiding phase of pressure-flow study in these patients, mean Pdet Q(max) showed a significant decrease postoperatively from 58.5 cmH2O to 3.0 cmH2O (p < 0.01), although mean abdominal pressure at Q(max) significantly increased from 24.2 cmH2O to 105.8 cmH2O (p < 0.05). Mean Q(max) on free uroflowmetry showed a significant increase from 12.8 ml/sec to 22.1 ml/sec (p < 0.05). No patient had significant post-void residual urine. On the storage phase of the study, however, maximum cystometric capacity, maximum urethral closing pressure showed no significant change between pre- and post-operative studies. Five patients acquired continence and one had mild urinary incontinence using one pad a day. The present study showed that detrusor contaractility could be impaired during radical prostatectomy, but, no apparent operative procedure related to detrusor dysfunction could be identified in the present patients.

Oxycodone is a useful analgesic for cancer patients in pain. However, its pharmacokinetics have not been sufficiently examined and there is a lack of information, with very few reports on pharmacokinetics concerning the absorption process in particular. With this in mind, we studied the pharmacokinetics of controlled-release oxycodone (Oxy contin). We measured its serum concentration in patients with cancer pain, and calculated parameters derived using the nonlinear least-squared method program (MULTI). In the result, pharmacokinetic parameters calculated at CL/F were: 45.6+/-22.0 L/hr (Mean+/-SD), Vd/F: 473.0+/-19 6.7 L, t(1/2): 7.2+/- 6.2 hr, kel: 0.103+/-0.034, kal: 1.082+/-0.604, Lag time: 0.9 9+/-0.40 hr. In addition, the serum oxycodone concentration hardly rose until 1 hour after and just before medication, whereupon a rapid increase was evident after 1 hour. The pharmacokinetics of controlled-release oxycodone in patients with cancer pain were clarified in this study. Especially during the absorption process, the lag time was calculated specifically at about 1 hour, making it approximately equal to MS contin.

The NPO Biomedical Science Association provided telephone consultation, including contacts by fax and email, targeting the general public within the framework of influenza control measures worked out by the Japanese Ministry of Health, Labor and Welfare (MHLW). We received 2,813 inquiries during the 2003-2004 flu season and 2,444 inquiries during the 2004-2005 season. By month, the highest number was in October-November, accounting for 42.6%. The preceding season showed a similar trend. By gender, 72.5% of those seeking advice were women. By area of residence, the highest number was living in metropolitan Tokyo, and the remainder lived in the prefectures of Kanagawa, Chiba, Saitama, Nagano, Shizuoka, and Ibaraki in this order. We received no inquiries from the prefectures of Shimane or Saga. By occupation, housewives accounted for 1,114 inquiries (45.6%), followed by private companies with 447 inquiries (18.3%) and health-care providers with 227 inquiries (9.3%), similar to the 2003-2004 flu season. By subject, 1,545 inquiries concerned vaccines (62.2%) mainly, the pros and cons of vaccination, adverse reactions, and the number of inoculations required. Inquiries about pregnancy, infants and young children, and breast-feeding accounted for 19.2%. Inquiries on vaccine shortages during the 2004-2005 flu season (7), SARS (22), and bird flu (22) decreased compared to the previous season, while the number of consultations on antiviral agents increased (209). In discussing how information on influenza should be communicated to the public, we propose that "Influenza Q & A" provided by the Infectious Diseases Surveillance Center of the NIID, MHLW, should include information on influenza specifically addressing pregnant woman and breast-feeding or child-rearing mothers.

Von Hipple-Lindau (VHL) disease is a rare familial cancer syndrome that is dominantly inherited and pre-disposes affected individuals to developing various tumors, including hemangioblastoma of the retina and central nervous system, and multicentric renal cell carcinoma. We report two cases of VHL disease with bilateral renal cell carcinoma. Case 1: A 53-year-old woman was referred to our hospital because of bilateral kidney tumor incidentally found. We performed left laparoscopic radical nephrectomy and laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation for the right kidney. Case 2: A 43-year-old woman was referred to our hospital because of left kidney tumor incidentally found. Because the suspectious lesion in the right kidney was very small, we decided to follow it up with no treatment. We performed laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation for left kidney.

Objectives: To evaluate whether the response to antiarrhythmic drug therapy in patients with paroxysmal atrial fibrillation affects the development of structural remodeling in the left atrium and ventricle., Methods: This study included 230 patients (158 men and 72 women, mean age 67 +/- 11 years) in whom antiarrhythmic drug therapy was attempted for > or = 12 months to maintain sinus rhythm (mean follow-up period 45 +/- 27 months). The patients were divided into three groups according to the response to antiarrhythmic drug therapy: group A consisted of 78 patients without recurrence of atrial fibrillation, group B consisted of 87 patients with recurrence of atrial fibrillation and electrical and/or pharmacological cardioversion to restore sinus rhythm, and group C consisted of 65 patients with permanent conversion despite antiarrhythmic drug therapy., Results: In group A, left atrial dimension (LAD), left ventricular end-diastolic dimension (LVDd), and left ventricular ejection fraction (LVEF) did not change after antiarrhythmic drug therapy. In group B, LAD increased significantly after antiarrhythmic drug therapy (from 32.6 +/- 6.4 to 36.0 +/- 6.5 mm, p < 0.01), Whereas either LVDd or LVEF did not change after antiarrhythmic drug therapy. In group C, LAD increased significantly after antiarrhythmic drug therapy (from 37.3 +/- 7.0 to 40.5 +/- 7.9 mm, p < 0.01) and LVEF was significantly reduced after antiarrhythmic drug therapy (from 69.4 +/- 6.2% to 66.5 +/- 8.9%, p < 0.05). LVDd did not change after antiarrhythmic drug therapy. The plasma concentration of human atrial natriuretic peptide during sinus rhythm at the initiation of antiarrhythmic drug therapy in group A (30.5 +/- 26.7 pg/ml) was significantly lower than those in group B (48.0 +/- 49.7 pg/ml) and group C (49.7 +/- 39.5 pg/ml)., Conclusions: The development of structural remodeling in human myocardium can be prevented with antiarrhythmic drug therapy if sinus rhythm is maintained without recurrence of atrial fibrillation in patients with paroxysmal atrial fibrillation.

Spinal anesthesia has been often used for inguinal herniorrhaphy. With the advancement of surgical technique, tension free inguinal herniorrhaphy is now performed under local anesthesia. Local anesthesia, however, does not always offer sufficient anesthesia. We performed psoas compartment block with 1% lidocaine in a 78-year-old man undergoing tension free inguinal herniorrhaphy. During the operation, the patient felt pain and needed additional local anesthesia once. But the pain was not severe, and he did not feel stressed. Advantages of psoas compartment block for inguinal herniorrhaphy are its easiness to perform, little burden of anesthesia and high efficacy. Demerits are slow onset of block and necessity for prolonged patient monitoring. Further investigations on dose and patient position are required for psoas compartment block to become useful for inguinal herniorrhaphy.

We retrospectively reviewed the clinical results of 24 patients who underwent laparoscopic partial nephrectomy by a diagnosis of renal cell carcinoma (RCC) between 1999 and 2004, including 16 elective cases and 8 imperative cases. Twenty-two were successfully treated laparoscopically; two cases in the imperative group required conversion to open surgery because of uncontrollable bleeding. A vascular clamp was used in 12 cases for an average of 26 minutes. The creatinine clearance changed from 98 to 93 ml/min in the elective cases and from 49 to 44 ml/min in the imperative cases. Pathological evaluation revealed RCC in 10 elective cases and 6 imperative cases. Local recurrence (renal hilum lymph node and ipsilateral kidney) was found in 2 patients in the imperative group. Although laparoscopic partial nephrectomy is useful, long-term follow-up is necessary for evaluating the tumor control.

Objectives and Methods: The factors controlling the preventive effect of long-term amiodarone therapy were evaluated in patients with paroxysmal atrial fibrillation. The 55 patients (37 men and 18 women, mean age 68 +/- 9 years) with paroxysmal atrial fibrillation refractory to more than two types of Class I antiarrhythmic agents received amiodarone (100-200mg/day) after electrical or pharmacological cardioversion. All patients were observed for 12 months or more (mean follow-up period 48.6 +/- 29.1 months)., Results: Actuarial recurrence-free rate at 12 months in patients with ejection fraction < 55% (76.5%, n = 17) was significantly higher than that in patients with ejection fraction > or = 55% (44.7%, n = 38) (p = 0.0411), and tended to be higher in patients with underlying heart disease (65.5%, n = 29) than in patients without underlying heart disease (42.3%, n = 26) (p = 0.0980). Age, sex, diabetes mellitus, alcohol intake, hypertension, hyperlipidemia, and administration of angiotensin converting enzyme inhibitor were not related to the effect of amiodarone. Relative risk reduction of recurrence after amiodarone therapy was 4.01 (95% confidence interval 3.57-4.45) in patients with ejection fraction < 55%, and 2.59 (95% confidence interval 2.07-3.11) in patients with underlying heart disease. None of the above-mentioned factors was related to the development of adverse effects. The incidence of adverse effects requiring discontinuation in all patients was 7.3%., Conclusions: Amiodarone was more effective for preventing recurrence in patients with poorer left ventricular function and underlying heart disease.