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Osteopetrosis is a heterogeneous group of heritable conditions. It varies greatly in severity, and fracture treatment remains a matter of controversy due to altered responses to fixation and the risk of osteomyelitis. Therefore, sternotomy outcomes in this condition are unclear. We report the case of a patient with osteopetrosis and coronary artery disease (CAD). A 78-year-old man with osteopetrosis presented with frequent chest pain. Coronary angiography revealed two-vessel CAD. Percutaneous coronary intervention was contraindication because of coronary aneurysm in the left main trunk. Considering risks in median sternotomy, we performed minimally invasive cardiac surgery through left minithoracotomy for coronary artery bypass grafting( CABG). But we needed to break the left fourth rib to obtain sufficient surgical views. To the best of our knowledge, this is the first case report on CABG for a patient with osteopetrosis and endoscopic surgery without rib retractor is recommended.

In 1999, with the report "To Err Is Human: Building a Safer Health System" from the Institute of Medicine of the United States Academy of Sciences, social needs for quality assurance and improvement in medical care increased. Restructuring of clinical education and quality assurance of medical education were proposed as measures to improve the medical care delivery system and improve the quality of medical care. Outcome-based education (OBE) has become a global standard to ensure the quality of medical education. Medical education in Japan has also undergone a paradigm shift from the process-based education to OBE, in which learning outcomes are clearly indicated and achieved. An implementation of pharmacology to OBE was constructed in four steps. Step 1 is to set learning outcomes, Step 2 is to create learning strategies according to sequential performance levels for each competency, Step 3 is to create learning outcome evaluation methods, and Step 4 is to verify and improve the entire curriculum. As milestones for graduation that lead to learning outcomes, we have independently formulated the outcome of being able to safely prescribe the optimal drug (under the guidance and supervision of a preceptor) based on the treatment plan and with the patient's and family's explanations and consent. Learning objectives related to pharmacotherapy were extracted from the 2022 revision of the medical education model core curriculum. We created a curriculum and an evaluation method for learning outcomes, and introduced the Chiba University School of Medicine's efforts to verify and improve the entire curriculum.

A 60-year-old woman was not accompanied by any symptom. She had a gallstone which was identified 20 years prior. Ultrasonography performed by a local doctor revealed that the gallbladder was filled with small stones, and the patient was referred to our department for further examination and treatment for gallbladder stone. Tumor markers are elevated. Contrast- enhanced CT revealed gallbladder stones and thickening in the gallbladder body. PET-CT showed abnormal accumulation of FDG-PET with SUVmax 3.6 in the body of the gallbladder. With a diagnosis of gallbladder cancer, extended cholecystectomy and gallbladder bed resection with regional lymph node dissection were performed. The tumor was diagnosed histologically as small cell type neuroendocrine carcinoma of the gallbladder(pT2a[SS], pN0, pStage ⅡA; Japanese society of hepato-biliary-pancreatic surgery, the 7th edition). The postoperative course was uneventful. This patient has been followed up for 8 years without obvious signs of recurrence. R0 resection and lack of lymph node metastasis can allow long- term survival.

We report the case of a 74-year-old woman who underwent mitral valve plasty for mitral regurgitation. During the surgery, the ascending aorta was dilated and turned dark red after aortic cannulation. Intraoperative transesophageal echocardiography and direct epiaortic echography revealed type A aortic dissection. In addition to mitral valve plasty, replacement of the ascending aorta was performed under hypothermic circulatory arrest. The postoperative course was uneventful. Because intraoperative aortic dissection is a rare complication, its rapid identification and appropriate management is essential.

Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by hemolysis, thrombosis, and bone marrow failure. Infection, pregnancy, and surgical operation have the potential to evoke severe episodes of hemolysis and thrombosis. Therefore, the use of an antibody agent against complement component 5 (C5), eculizumab, one day before the operation is recommended. Ravulizumab is a newly approved long-acting antibody agent against C5. Thus, little is known about perioperative management with ravulizumab. We experienced a 43-year-old female patient who safely underwent laparoscopic cholecystectomy under ravulizumab treatment for PNH. Ravulizumab was administered one day before the operation. Laparoscopic cholecystectomy for cholelithiasis was performed under intravenous anesthesia, intermittent air compression of the lower extremities, and low pneumoperitoneum pressure. Additionally, heparin was administered, and the patient left the sickbed early without significant postoperative complications. Like eculizumab, complement inhibition by ravulizumab is also considered effective in the perioperative management of patients with PNH. However, close cooperation with surgeons and anesthesiologists and careful management based on clinical symptoms and laboratory data such as LDH, CH50, and D-dimer are essential.

A 52-year-old female had cholecystoduodenostomy for biliary atresia of type I cyst at 120 days of age. The patient's surgery recovery was uneventful;however, the patient had recurring cholangitis at the age of 27. The patient had high hepatobiliary enzymes in the outpatient clinic and was diagnosed with cholangitis. In general, the Kasai method is the mainstream for biliary atresia, since it has a much-reduced incidence of both early and late postoperative problems. However, this patient had biliary atresia of type I cyst and had undergone cholecystoduodenostomy. We suspected that the obstructive cholangitis was caused by the relatively wide anastomosis opening into the duodenal bulb, where the stomach contents pass through the most, and the poor clearance owing to the convoluted cystic duct;therefore, we chose to place a stent endoscopically. However, to our surprise, Class V was detected in the bile cytology performed as a precaution. Although no tumor was seen on imaging such as contrast-enhanced CT, EUS, and PET/CT, mapping biopsy results showed the presence of cancer at the bifurcation of the cystic duct. The patient had cholangiocarcinoma confined to the extrahepatic bile ducts only;thus, extrahepatic bile duct resection was conducted. The patient was discovered to have biliary intraepithelial neoplasia-3, and the tumor was entirely respectable. The patient had a good postoperative course, with normalization of liver function and no recurrence of cholangitis. In this case, cholangiocarcinoma was detected at an early stage by cytological examination performed as a precaution during endoscopic therapy for recurrent cholangitis. In addition to the fact that the long-term pathogenesis of biliary atresia is still unknown, it is important to note the presence of malignancy, which has the greatest effect on the patient prognosis, considering that the course of the disease varies depending on the operation carried out. Because cholecystoduodenostomy for biliary atresia is a rare approach, and there has been no previous report of related cholangiocarcinoma, we report this case for the benefit of gastroenterologists who may encounter similar cases in the future.

A 77-year-old man with a medical history of hypertension, dyslipidemia, angina pectoris, and internal carotid artery stenosis underwent laparoscopy-assisted distal gastrectomy, D2 lymphadenectomy, and Billroth Ⅰ reconstruction for advanced gastric cancer. Hematologic examination revealed severe anemia on postoperative day 2, and abdominal CT scan detected contrast media leakage into the remnant gastric lumen. Upper gastrointestinal endoscopy revealed mucosal necrosis and ulceration of a large range. The patient recovered with conservative treatment and was discharged on postoperative day 18. Endoscopic balloon dilation was required to improve anastomotic stenosis after discharge, after which the patient received adjuvant chemotherapy. The stomach is resistant to ischemic changes because of the microvascular networks in the stomach wall; thus, gastric remnant necrosis after gastrectomy is rare. However, for patients with arterial sclerosis, such as in this case, physicians must consider the range of gastrectomy and reconstruction methods.

An 83-year-old woman visited our emergency department with a chief complaint of abdominal pain and vomiting. Abdominal computed tomography showed thickening of the wall of the small intestine in the right middle abdomen and marked bowel dilation and fluid retention in the oral side of the small intestine. The patient was diagnosed with adhesive bowel obstruction and hospitalized for conservative treatment. However, the treatment was unsuccessful, and laparoscopic surgery was performed. The intraoperative findings included thickening of the wall and hardening of the obstructed part, suggestive of an intestinal tumor; thus, this part was resected. A histopathological examination revealed diffuse infiltration of large-sized atypical lymphocytes in the tumor, and diffuse large B-cell lymphoma was diagnosed through immunochemical staining. The postoperative course was uneventful, and the lymphoma has not recurred. Intestinal malignant lymphoma rarely causes bowel obstruction without invagination. Here, we report this case and review the literature.

The patient was a 59‒year‒old woman. In 2005, she underwent low anterior resection plus D2 dissection for rectal cancer (pT4aN2aM0, pStage Ⅲb). In 2007, she underwent hepatic S8 subsegment resection for liver metastasis. After that, FOLFIRI therapy was performed as chemotherapy for recurrence of the right upper lung lobe and para‒aortic lymph node(PALN). CR was once obtained in both(of)PALN and lung, but PALN re‒expansion and left ovary enlargement were observed in 2009, and resection of PALN plus left ovariectomy was performed. Histological examination showed PALNs were metastases from rectal cancer and the ovary was benign. Eleven years after the first operation, she stayed alive without recurrence.

A case of 69-year-old man underwent resection for the plantar surface of left foot malignant melanoma and received a sentinel biopsy of left inguinal lymph node. Two years and 10 months later, a mass of 30 mm in diameter in the ileum was detected by contrast-enhanced computed tomography, which showed abnormal uptake using FDG positron emission tomography. The partial intestinal resection was performed, and then, the mass was diagnosed as metastasis of malignant melanoma by pathological examination. Malignant melanoma is highly malignant disease that frequently shows distant metastasis. Although the malignant melanoma with distant metastasis shows poor prognosis, previous studies reported the prognosis could be improved when the patient could receive curative resection for single intraabdominal metastasis. Therefore, surgical resection should be considered for the single metastasis of malignant melanoma. We report a case of malignant melanoma with ileum metastasis resected curatively with literature review.

A 63-year-old-woman was diagnosed with gastric cancer cStage ⅠA after ESD, and then, underwent robot-assisted distal gastrectomy. She vomited on the postoperative day 2 and then was inserted nasogastric tube. The amount of drainage from the tube was increased on the postoperative day 5, therefore, abdominal computed tomography scan was performed, which showed herniation of small bowel at the 8 mm port site in the left upper abdomen. The emergent surgery was performed because of difficulty in manual reduction. Intraoperative findings showed that small intestine was incarcerated at the left 8 mm port-site. The intestine was released by incising the fascia of hernia orifice, then, the fascia was repaired. There was no recurrence of gastric cancer and port-site hernia for 34 months after surgery. In general, the fascia of over 10 mm port site is sutured and closed to avoid port-site hernia, however, it is unclear whether the fascia of 8 mm port-site should be closed after robotic surgery. Since we experienced this case, we have also performed fascia suture on the 8 mm port-site in all cases. And then, we could prevent occurrence of port-site hernia in the 8 mm port-site.

A questionnaire survey was conducted regarding the prognosis for pancreatic cancer at 8 major hospitals in Yamaguchi Prefecture. A total of 552 patients with pancreatic cancer who underwent radical surgery between 1997 and 2016 were identified. Five of them survived for more than 10 years. Among the 5 patients, none was treated with neoadjuvant chemotherapy: 4 underwent PD and 1 underwent DP-CAR. Two of them were treated with adjuvant chemotherapy. No complications occurred during their postoperative courses. All of them had no recurrence and survived. Here, we reported the longterm postoperative survival of patients with pancreatic cancer with literature review.

Background: FoundationOne CDx is a cancer genome profiling test that has already been approved by the FDA, but its clinical utility in Japanese patients is unknown. In this study, we examined the clinical utility of FoundationOne CDx., Methods: 46 samples from 43 Japanese pretreated patients with advanced solid tumors were tested with FoundationOne CDx between September 2018-January 2019., Results: The median age of 43 patients was 63 years(ranged 18 to 82 years), and among them 24 were males and 19 females. Major cancer types were hepato-biliary and pancreatic(8 cases)and other digestive organs(8 cases). All 27 cases in which genome cancer board had been completed by January 17, 2019 were analyzable, and the number of detected gene mutations(except VUS)was an average of 4.3(ranged 0 to 14)per case. Of the 27 cases, one or more mutations were found in 26 cases(96%), and in all such 26 cases actionable mutations with candidates for therapeutic agents were found. In 4(15%)of them, the treatment corresponding to the gene mutation was performed. Among the cases in which target disease matched and clinical trials of the drug were being conducted in Japan, only one case participated in the trial. The most common reason for not participating in the trial was disease deterioration and PS reduction (33%)., Conclusions: The FoundationOne CDx test showed that it can detect gene mutations in various cancer types in Japanese patients.

A 52-year-old man whose fecal occult blood test was positive was found to have type 2 sigmoid colon cancer by colonoscopy. On enhanced barium enema study, the cecum was in the pelvis, and the ascending colon was running medially in the abdomen. Enhanced CT scan of the abdomen revealed rotation of the superior mesenteric vein(SMV). We diagnosed the case as sigmoid colon cancer(cT3N0M0, StageⅡA)with non rotation-type intestinal malrotation, and performed laparoscopic surgery. We confirmed the small intestine to be located on the right side of the abdomen, the cecum to be located in the pelvis, and the ascending colon to be running medially in the abdomen. The ascending mesocolon was adherent to the right of the sigmoid mesocolon. Following dissections of the ascending mesocolon from the sigmoid mesocolon, we performed surgery via the inside approach as usual. We dissected the root of the inferior mesenteric artery(IMA), and the operation was completed. In laparoscopic surgery for colorectal cancer with intestinal malrotation, there are some reports that it could be performed safely if attention is paid to adhesion of the mesenteries and vascular variation in the course of preoperative imaging diagnosis. We report a case of laparoscopic surgery that could be safely performed for sigmoid colon cancer with non rotation-type intestinal malrotation.

The biological actions of testosterone(T) and estrogens(E) are mediated via androgen receptor(AR) and estrogen receptor(ER), respectively. Testosterone also exerts its effect by conversion to estrogens by aromatase in peripheral tissues. Recently, from the detailed analysis of the phenotype of human or mouse mutant of AR, ER and aromatase, T-AR, E-ERs are protective against metabolic syndrome(MetS) and diabetes mellitus(DM). Both sex steroids are suggested to potentiate leptin signaling as a central mechanism and to suppress lipid synthesis and promote lipolysis as peripheral mechanism. Thus, the insufficiency of the amount or action of these sex steroids causes obesity and insulin resistance. Age-associated decrease of sex steroids is an important background for the onset of visceral obesity and life-related diseases.

A 57-year-old female developed dizziness and forgetfulness several days before admission. She was admitted to our hospital because of a headache and nausea. On admission, she had a mild disturbance of consciousness and right hemiparesis. Initial MR imaging revealed multiple infarctions in the acute-to-subacute phases in the right cerebellum, left occipital lobe, and bilateral parietal lobes. Her electrocardiogram showed atrial fibrillation and transesophageal echocardiography revealed the presence of a thrombus at the left atrial appendage, suggesting that she suffered from cardioembolic stroke. Laboratory testing showed elevated free T4 levels and low thyroid stimulating hormone (TSH) levels with positive anti-TSH receptor antibodies, indicating untreated Basedow disease. Although treatment with anticoagulants and methimazole was initiated, her postural tremor, tachycardia, and psychosis deteriorated. On the 8th day of admission, thyrotoxic crisis was confirmed. Despite increased doses of methimazole, as well as treatments with inorganic iodine, steroids, and β-blockers, her psychosis prolonged even after her thyroid function was normalized. Long-term use of antipsychotic medications was required to treat her psychosis. In this case, neurotoxicity of the anti-TSH antibodies related to Basedow disease may have caused prolonged psychosis because of the extensive damage to the blood-brain-barrier function following multiple ischemic strokes. Careful observation and treatment are required for psychotic symptoms, in addition to the treatment for acute stroke in such cases, where thyrotoxic crisis is associated with ischemic stroke.

The research to develop a drug, so called selective androgen receptor modulator (SARM) , which shows beneficial androgenic action on bone and muscle, but hardly possesses the stimulatory action on prostate has been making a progress. However, no drug is available in the market at present. Most of such drugs are developed, aiming at the application to age-related muscle reduction (sarcopenia) and osteoporosis. Recently, in a clinical trial of SARM (enbosarm) administration to healthy elderly men, a promising data showing the increase of lean body mass and physical function has been reported. Future clinical applications of SARMs are expected.

Purpose: To evaluate location, treatment and clinical course in cases of ocular surface squamous neoplasia (OSSN)., Methods: Thirty-four cases with OSSN [conjunctival intraepithelial neoplasia (CIN) 17 cases; squamous cell carcinoma (SCC) 17 cases] treated in Kyushu University hospital from 2000 to 2011 were retrospectively studied., Result: Lesions of CIN were observed in the conjunctiva bulbar in sixteen cases (16/17), and in eleven of those, the lesions were seen in the nasal part (nasal : lateral = 11 : 6). The lesions of eight SCC cases (8/17) were observed in the conjunctiva bulbar, of seven cases (7/17) were observed in the conjunctiva palpebral, and of two cases (2/17) in the fornical conjunctiva. Significantly far more cases of SCC in the conjunctiva bulbar were seen in the nasal part compared to the lateral part (nasal : lateral = 7 : 1). Most SCC lesions in the conjunctiva palpebral and fornix were observed in the upper eyelid (upper : lower = 6 : 3). CIN were treated by excision in nine cases (9/17), excision after topical chemotherapy in three cases (3/ 17), and topical chemotherapy in 5 cases (5/17). Nine SCC patients were treated by excision (9/17), four by excision after topical chemotherapy (4/17), and four by radiotherapy (4/17). Three cases of CIN and one case of SCC had recurrence and needed further treatment., Conclusion: The use of preoperative chemotherapy and radiotherapy for OSSN patients seems useful for a good outcome.

There is no concept of rare disease (RD) but Nambyo (intractable disease) since 1972. In 1995 the definition of Nambyo included the concept of rareness and the frequency for a Nambyo is less than 50000 in Japanese population. Currently Nambyo are selected for special research support, and special treatment of medical expenses. The budget for research is 10 billion yen. The approximate number of medical recipients is estimated to be 700000. The measures already developed for Nambyo are not comprehensive, therefore currently several additional measures are being envisaged. We are now planning to join the Orphanet. The expectations for Orphanet Japan are to: Enhance international collaboration of RD, providing international up-to-date information of RD in Japanese, inform historical and up-to-date research of Nambyo, and promote information exchange, joint research and network establishment. It is necessary to make a Patient Registry for rare disease, and hopefully have a structure to integrate worldwide registry with same concept. Recently "International Rare Disease Research Consortium (IRDiRC)" was formed. The purpose of this consortium is to make an international coordination of the rare disease research, and to integrate the knowledge of the rare disease research. We will also talk about the Patient Registry by Patient Advocacy group, including Patient Reported Outcome (PRO).

Recent studies have revealed considerable evidence for our understanding of the mechanisms underlying the development and maintenance of chronic pain including neuropathic and inflammatory pain. It is considered that plastic changes in the spinal dorsal horn contribute to the amplification of pain signaling. Moreover, persistent pain affects brain function and also the endogenous descending pain regulatory system. To characterize these pathophysiological changes and pharmacological properties in chronic pain conditions at the synaptic level, we have employed in vitro electrophysiology in slices of the spinal cord and supraspinal regions such as brainstem and hippocampus of adult mice and in vivo electrophysiology in anesthetized rats. In particular, we have successfully prepared spinal slices with an attached dorsal root, where A-fiber- or C-fiber-evoked monosynaptic excitatory postsynaptic currents or miniature excitatory postsynaptic currents were recorded from voltage-clamped dorsal horn neurons. In anesthetized rats, C-fiber-evoked field potentials were recorded from the spinal dorsal horn in response to electrical stimulation of the sciatic nerve fibers, and their long-term potentiation was elicited to mimic increased synaptic efficacy after peripheral nerve injury. Of interest is the finding that some drugs exerted the injury-specific effects on synaptic transmission, thus strongly suggesting the importance of pharmacological analysis at the synaptic level combined with electrophysiological techniques to obtain pathophysiological information and new insights into drug research in this field.

Natural orifice translumenal endoscopic surgery (NOTES) is considered the ultimate minimally invasive intervention for visceral disease. The transvaginal route is now the only one that can be used for NOTES procedures in daily clinical practice. We performed hybrid NOTES appendectomy that was preevaluated and approved by the Japan NOTES and Institutional Review Board. A 5-mm trocar was inserted transumbilically and used for laparoscope access. An additional transumbilical 2.3-mm port was placed, through which the surgeon inserted a grasper. We created a transvaginal port with a long 12-mm trocar. Laparoscopic instruments such as a vessel sealing system, surgical staplers, and a retrieval bag were introduced, and the surgical technique consequently became safer, although the access route was limited. The appendix was removed transvaginally. The patient did not need epidural anesthesia or any pain medication. The cosmetic results were better than that of conventional single-port surgery. Triangulation is achieved in this procedure, which makes the surgery easier. To generalize NOTES to many types of surgery and enable it to be performed in men, the transgastric approach is essential. The development of flexible instruments designed for NOTES is also necessary.

A 60-year-old woman declared brain dead was scheduled for organ donation. We continuously measured total hemoglobin values (SpHb) using a Radical-7 monitor (Masimo Co, Irvine, CA, USA) to maintain the functions of organs and oxygen delivery. At the start of surgery, the SpHb value was 9.3 g x dl(-1). Packed red blood cells were transfused immediately No anesthetics or opioids were used during the operation. Blood pressure suddenly decreased to below 80 mmHg because of bleeding, manipulation of organs, and/or compression of the vena cava. Six units of red blood cells and 900 ml of colloids were rapidly transfused with real-time monitoring of SpHb values. On cross-clamping of the aorta, the SpHb value increased up to 10.2 g x dl(-1). The heart, lungs, liver, pancreas, and kidneys were donated from the patient without organ dysfunction. The highlight of this case report is that anesthesiologists could use SpHb monitoring for management of hemodynamics in a brain-dead organ donor.

It has been eight years since the postgraduate clinical training system was implemented in Japan. This training system is now being reviewed. Some issues on learning objectives and training programs have been pointed out. Outcome-based clinical training is necessary to assure quality of the postgraduate clinical training system and to achieve accountability to the society. Learning objectives should be redefined as competencies and authentic assessments like a workplace-based assessment of mini-CEX should be implemented to improve this system.

Gadoxetate Sodium (Gd-EOB-DTPA) is a relatively new contrast agent used for liver examination by magnetic resonance (MR) imaging. The setting of the flip angle (FA) is very important to obtain images with high contrast in hepatocellular MR imaging. The aim of this study was to determine the optimal FA for hepatocellular MR imaging. Optimal FA was estimated using a visual evaluation by observers. We made the visual evaluation with a paired comparison test. When the overall characteristic showed a significant difference, we then evaluated the optimal FA using a yardstick analysis. The visual evaluation by observers indicated that the FA was best at 22 degrees for the overall characteristic, the contrast characteristic, and the sharpness characteristic, and for the noise characteristic, the best FA was 18 degrees. All characteristics showed a significant difference between 18 and 22 degrees. Based on our results, the most important factor was the contrast characteristic for the visual evaluation, and we concluded that the optimal FA in hepatocelluar MR imaging was 22 degrees.

Gambir (asen'yaku in Japanese), an aqueous extract of leaves and young twigs of Uncaria gambir Roxb., has traditionally been used as a treatment for diarrhea and dysentery as an internal medicine and for sore throat as a gargle. Although it is a pharmacopoeic medicine in Japan, the quantitative evaluation of its constituents has not yet been adopted in the Japanese pharmacopoeia. We analyzed polyphenolic constituents in 31 gambir and related products to establish evaluation methods, since gambir contains large amounts of polyphenolic constituents. The total flavan contents in the samples revealed using the vanillin-HCl estimation method ranged from 24-79%. Reversed-phase high performance liquid chromatography (RP-HPLC) analysis indicated that catechin was the most abundant constituent in each sample, with contents in the range of 7-76%. The catechin contents in the gambir products between the first and third quartiles were 28-54%. Thus, the lower limit of the catechin content in gambir products can be set at around 20% for quality management. Fifteen tested samples were subjected to HPLC analysis to show the presence of epicatechin (1.5% on average) and the dimeric compounds procyanidin B1, procyanidin B3, and gambiriin A1 (ca. 1% each). The molecular weight distributions of polymeric flavans in the gambir products were analyzed by gel permeation chromatography (GPC) and showed that the average degree of polymerization for each sample was 3 to 7. These results indicate that the combination of the vanillin-HCl method, RP-HPLC analysis, and GPC analysis gives valuable information for evaluating the polyphenolic profiles of gambir products.

A 79-year-old man was admitted to our hospital with right hypochondrium pain. His chest X-ray and CT scan showed a mass lesion on the left upper lobe, and multiple metastases in the liver. The diagnosis was non-small cell carcinoma of the lung. He received 4 courses of combined chemotherapy of carboplatin and docetaxel every 4 weeks. At the end of 4 courses, a partial response was achieved. Two courses of a in similar regimen were added at the time of a later recurrence, and the effect was a partial response. Carboplatin+docetaxel combined chemotherapy, which can be conducted relatively safely on an outpatient basis, may be an effective treatment for non-small cell lung cancer in the elderly.

We report a case on hemodialysis with metastatic rectal cancer who was introduced to CPT-11. Although the expected pharmacokinetics was shown 24 hours post-dialysis with the infusion of dose-reduced CPT-11, grade 4 neutropenia was observed. Considering the chronic renal failure status with latent lower function of multiple organs, the dose escalation method was recommended while watching the pharmacokinetics. CPT-11 is not only the key compound for metastatic colorectal cancer, but is also effective with several other cancers. It is important for cancer patients with chronic renal failure that the feasibility and efficacy of CPT-11 should be determined by future study.

We studied 35 ears of 34 patients with congenital cholesteatoma who were operated between June 1992 and May 2003, focusing on the localization and progression of congenital cholesteatoma. Patients were 2 to 55 years of age. Congenital cholesteatoma was diagnosed based on two intraoperative findings: 1) no continuity between the tympanic membrane and cholesteatoma, 2) no presence of perforation, retraction, or granulation of the tympanic membrane. All patients had closed-type cholesteatoma, and none formed open-type cholesteatoma, which grows as a flat sheet of epidermis. The primary site of congenital cholesteatoma was classified into 3 types; 1) anterior-superior quadrant, 2) posterior-superior quadrant, and 3) epitympanic, and the origin of these three types of congenital cholesteatoma was difficult to explain by a single theory. We operated on 31 ears by canal wall up tympanoplasty and on 4 ears by canal wall down tympanoplasty. On all but 4 ears, we performed planned-staged operation, including second-look operations, in case of recurrence or residual cholesteatoma. Improvement in hearing after surgery was seen in 22 of the 26 ears treated and followed up for more than 6 months after surgery. By drawing all localization of congenital cholesteatoma in 35 ears, we studied the progression of congenital cholesteatoma and speculated on the original primary site. Congenital cholesteatoma in restricted areas consequently implies good results in hearing after surgery, making earlier diagnosis and treatment desirable.

It has been well established that the liver can regenerate after resection. Liver regeneration is a fundamental mechanism by which the liver responds to injury. This review article discusses molecular and cellular mechanism of liver regeneration, including growth factors and cytokines in the initiation and regulation of liver regeneration, the importance of the liver extracellular matrix and its dynamic effect on hepatocyte growth, and finally, stem cell biology in liver regeneration.

Objective: In order to study the gender-related effects of weight reduction on the physical condition of male and female college judoists during weight reduction periods, we examined changes in anthropometric, nutritional intake and biochemical parameters in 43 male and female college judoists 20 days (pre-weight reduction) before and one day (post-weight reduction) before the game., Methods: Subjects were divided into two groups. Thirty subjects (22 males, 8 females) who required weight reduction were defined as the weight reduction (WR) group, and the remaining 13 subjects (5 males, 8 females) were defined as the non-reduction (non-WR) group., Results: In both WR groups, anthropometric parameters and nutritional intake significantly decreased after weight reduction compared to the pre-values. The change ratios of nutritional intake during the weight reduction period in the female WR group were higher than those in the male WR group. Serum lipids and electrolytes significantly decreased after the weight reduction compared to the pre-values in both WR groups. In the female WR group, Cr and UA significantly increased after the weight reduction compared to the pre-values. Although it was not significant, Ht increased after the weight reduction compared to the pre-values only in the female WR group. TP, Cr, UA, BUN, CK, LDH and IgA significantly increased after the weight reduction compared to the pre-values in the weight reduction compared to the pre-values in the male WR group. In contrast, in both non-WR groups, these parameters did not change significantly during the research period., Conclusions: Our findings suggest that nutritional exhaustion and dehydration may be the major effects brought about by energy and fluid restriction in female college judoists during a weight reduction period. On the other hand, in male college judoists undergoing weight reduction, the data suggest that muscle damage and myogenic protein catabolism may be caused chiefly by exercise. These differences may be due to the difference in the method of weight reduction for the different genders, namely, mainly exercise in males and mainly energy and fluid restriction in females.

A 57-year-old woman first noticed difficulty in walking at the age of 34 years, and since then muscle wasting and weakness in the lower limbs and proximal portion of the upper limbs had progressed slowly. Serum CK was elevated. Immunohistochemical study of the biceps brachii muscle showed deficiency of dysferlin in sarcolemma, and the dysferlin gene analysis disclosed 3370 G-->T missense mutation. These findings led us to diagnose her as LGMD2B. Moreover echocardiogram revealed ventricular enlargement and diffuse hypokinesia suggesting secondary cardiomyopathy atributable to muscular dystrophy. Careful cardiac monitoring should be carried out in dysferlinopathy patients.

We conducted a retrospective study to identify the clinical features and surgical observations of congenital cholesteatoma. Sixty patients were diagnosed and underwent surgery for congenital cholesteatoma between April 1987 and May 2002. All diagnoses were made on the basis of two operative findings: 1. the tympanic membrane manifested neither retraction, perforation, nor granulation. 2. the tympanic membrane was not continuous with the cholesteatoma. In this series, congenital cholesteatoma accounted for 7% of all cholesteatomas (853 ears). The patient age ranged from 2 to 48 years. The male to female ratio was 4:1. Seventeen patients had multiple cholesteatoma. Fifty-three patients exhibited closed-type cholesteatomas, while the remaining 7 patients had open-type cholesteatomas that had formed as a flat surface of the epidermis. Patients with open-type cholesteatomas presented with a much more pronounced conductive hearing loss and ossicular erosion or malformation. Twenty-two patients with relatively small cholesteatomas were analyzed to estimate the origin of their cholesteatomas. Of the 22 patients, 13 had anterior superior quadrant (ASQ-type) and 9 had posterior superior quadrant (PSQ-type) cholesteatomas. The mean age at the time of detection was older in the PSQ-type group than in the ASQ-type group and the frequency of ossicular erosion or malformation was more prominent in the PSQ-type group than in the ASQ-type group. The primary site of origin was thought to be the portion between the tympanic ostium of the auditory canal and the semicanal for tensor tympani in the ASQ-type group and near the incudostapedial joint in the PSQ-type group. A planned staged procedure was performed in 29 patients, 15 patients (52%) had residual lesions situated mostly on the oval window, the round window, an exposed facial nerve or an exposed lateral semicircular canal. The frequency of residual lesions in patients who presented with extended, multiple cholesteatoma and those with ossicular malformation was comparable to the frequency of patients who did not present with these features.

In 29 ears of 24 patients with auditory ossicle malformation, but without external ear abnormalities, who were operated on at our clinic in the 10 years between June 1993 and June 2002, we studied the condition of ossicles, preoperative examination, surgical procedures, and postoperative hearing improvement. Our study did not include patients with cholesteatoma or those with only fixed stapes but without ossicular deformity. Samples were 12 ears of 11 men and 17 ears of 13 women. We clinically distinguished 3 major categories: (i) discontinuity between the incus and stapes with mobile stapes, (ii) congenital fixation of the stapes with ossicular deformity, and (iii) congenital fixation of the malleus and deformity of the incus with mobile stapes. We classified each category into minor abnormalities based on the condition of the long process of the incus, the superstructure of the stapes, and the stapes footplate. We conducted auditory ossicle reconstruction by mobilization of the malleus and incus in 2 ears, by type III tympanoplasty in 5 ears, by type IV tympanoplasty in 13 ears, and by stapes surgery in 8 ears. Improvement in hearing after the operation was observed in 25 of the 29 ears treated. In the classification of the auditory ossicle malformation without external ear abnormalities, we should evaluate discontinuity or fixation of the ossicles and their deformity. This requires that varied ossicular reconstruction be prepared for surgery, but the possibility of hearing improvement is high, so intensive treatment is needed in many cases of auditory ossicle malformation.

Theoretically, en bloc resection of the hepatoduodenal ligament is considered to be the most radical procedure for advanced carcinoma of the biliary tract. However, this procedure involves perioperative difficulties such as hepatic ischemia, portal congestion, patency of reconstructed vessels, and high incidence of operative mortality, moreover, when it is combined with resection of the liver and/or pancreas. We developed several tactics in vascular reconstruction, hepatic resection, and pancreatoduodenectomy in order to decrease the operative morbidity and mortality. We preferred to anastomose the portal vein and hepatic artery separately to avoid total hepatic ischemia, and used the porto-systemic bypass during prolonged portal reconstruction. We resected the liver without vascular clamping to minimize hepatic ischemia, and employed the simplified method of pancreatojejunostomy. To date, we performed 4 hepatoligamentectomies and 4 hepatoligament-pancreatoduodenectomies with no operative mortality, although long-term survivors were not encountered. This procedure should be evaluated with more clinical experiences after its safety and indication was established.

We retrospectively evaluated preoperative radioisotope (RI) scintiscans in 275 patients (283 glands) with parotid tumors who undergoing surgery between 1987 and 2000. Technetium-99m-pertechnetate (Tc) scintigraphy was conducted on 201 glands. Oncocytoma and Warthin's tumor showed a high positive rate. In evaluating Warthin's tumor with Tc scintigraphy, sensitivity was 75% and specificity 88%; above the age of 40 years, specificity exceeded 90%. Gallium-67-citrate (Ga) scintigraphy was conducted on 207 glands. Malignant parotid tumors showed high positivity (85%), but the specificity of positive findings was quite low (38%) because 44% of benign pleomorphic adenoma, which occupied major material, showed Ga-positive findings. Ga-negative findings indicated high probability (95%) of benign tumors. Thus, Tc scintigraphy is effective in diagnosing Warthin's tumor, while Ga scintigraphy is effective in diagnosing benign tumors.