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During the past decade, many high-alert medications have been developed and used in clinical practice. Particularly, in the pharmacotherapy of high-alert medications with large individual differences, more attention is needed. To achieve appropriate and individualized pharmacotherapy, there are many issues to be addressed from a clinical pharmacology perspective, such as enhanced monitoring and prior risk identification. This paper is focusing on the therapeutic drug monitoring of molecularly targeted anticancer drugs, and the provision of real-world evidence based on the clinical implementation of pharmacogenetic testing.

Malignant melanoma is an aggressive tumor with a high potential for distant metastases. Autopsy studies have shown that gallbladder metastases are found in 15% of patients. However, metastatic melanoma of the gallbladder is rarely discovered in living patients. A 73-year-old man was reported. The patient underwent surgical removal of malignant melanoma on his back and lymphadenectomy of the axillary lymph nodes. In addition, the patient developed cutaneous metastases to the right axillary and the middle of the chest 1.5 years after the surgery. Consequently, nivolumab chemotherapy was started. A computed tomography (CT) scan showed a well-enhanced mass in the gallbladder 4 months after. Abdominal ultrasonography revealed a 13-mm hypoechoic heterogeneous mass in the gallbladder with a hyperechoic layer on the mass surface. Magnetic resonance imaging demonstrated that the gallbladder tumor showed high signal intensity on T1-weighted images, low signal intensity on T2-weighted images, and high signal intensity on diffusion-weighted images. Positron emission tomography-CT revealed the slight uptake of fluorodeoxyglucose at the tumor. Endoscopic ultrasonography showed a hypoechoic tumor infiltrating the submucosal layer. The patient underwent open cholecystectomy. Examination of the resected specimens revealed a black, nodular-type tumor in the gallbladder body. The histopathological diagnosis was malignant melanoma. It was judged as metastatic melanoma of the gallbladder.

Objective: Erdheim-Chester disease(ECD)is a rare type of non-Langerhans histiocytosis. We report a surgical case of ECD with multiple lesions at the falx cerebri, tentorium cerebelli, and in the suprasellar region, with a literature review., Case Report: A 70-year-old woman presented with frequent falling and difficulty in standing. Her past medical history revealed ovarian cystectomy, transient thrombocytopenia, hypertension, left lower leg pain, and overactive bladder. Her head CT and MRI findings revealed well-defined mass lesions, suspected of meningioma, at the falx cerebri and tentorium cerebelli. Craniotomy and near total resection of the tumor at the falx cerebri was performed, leaving a hard portion of the tumor on the right falx. Intraoperative findings showed a solid and hard tumor, which was extremely difficult to decompress. Although the histopathological diagnosis was originally a metaplastic meningioma, considering her complaints of lower leg pain, we suspected ECD and performed a right tibial biopsy. The right tibial biopsy revealed ECD. Twenty-two months after the operation, the patient exhibited a marked enlargement of the tentorium lesion and a new lesion in the suprasellar region. Resection of the tentorial lesion was performed. The second intraoperative findings were similar to those of the first. The histopathological diagnosis of the tentorial lesion was ECD. After the surgeries, steroid therapy and radiation therapy were performed, but only with temporary improvement., Conclusion: ECD is a rare disease; therefore, accumulation of clinical data to establish its treatment is necessary.

The development of cancer genomic medicine has been embraced as an important new policy issue in "The 3rd Basic Plan to Promote Cancer Control Programs" formulated by the Japanese government. Cancer-associated gene panel testing has been recognized by the public health insurance system since July 2019, and is a critical component of the clinical implementation of genomic science. Because of this dynamic change in cancer medicine, pharmacists are now expected to acquire knowledge about genomic science, and to apply it to individualized and appropriate pharmacotherapies. This review outlines the roles of pharmacists in cancer genomic medicine.

Recently, there have been reports that the combination of renin angiotensin inhibitors, diuretics, and non-steroidal anti-inflammatory drugs increases the risk of acute kidney injury (AKI). This combination has been dubbed the "Triple Whammy". However, there have been no reports about its chronic effects on the kidney. In this study, we investigated the chronic effects of the "Triple Whammy" on kidney function. There were 203 outpatients who were prescribed this combination in our hospital for 5 years. We excluded patients who could also confirm the combination in the previous year and patients for whom laboratory data were unavailable, thus, leaving a target patient group of 95 patients. The average estimated glomerular filtration rate (eGFR) decreased significantly from 62.6 to 58.9 mL/min/1.73 m 2 immediately after administering the combination (p<0.01). Although no patients were diagnosed with AKI within 90 days after being administered the combination, 7.4% of patients exhibited a ≥25% reduction in eGFR compared with that before commencing the combination. Correlation analysis of gender, age, past renal function, and renal function change demonstrated that eGFR before administration of the combination negatively correlated with changes in eGFR (p<0.01). Considering the effects of individual differences, eGFR changes before and after administering the combination were compared using a case-crossover design and eGFR after administering the combination was found to be significantly reduced (p<0.01). Therefore, it appears that the "Triple Whammy" may cause not only AKI but also chronic renal degeneration.

Subcutaneous immunotherapy (SCIT) is a causative treatment for allergic diseases. More recently, it has become clear that regulatory T (Treg) cells are increased by SCIT. Treg cells are generally divided into two main groups: 1) CD25 + Foxp3 + CD4 + T cells (Foxp3 + Treg cells) and 2) IL-10-producing Foxp3 - CD4 + T cells (Tr1 cells). We demonstrated that the number of Tr1 cells in peripheral blood mononuclear cells in SCIT-treated pollinosis patients were significantly higher than that in non-SCIT-treated patients, but Foxp3 + Treg cells were not. Consistent with the results of human peripheral blood, Tr1 cells were increased in the lungs of asthmatic mice by SCIT, but Foxp3 + Treg cells were not. Moreover, in vitro-induced Tr1 cells were responded to the antigen to produce a large amount of IL-10 in in vitro and in vivo. Adoptive transfer of the induced Tr1 cells significantly suppressed the development of asthma. In any species of human and mouse, the increase in Tr1 cells rather than Foxp3 + Treg cells could be important for the effects of SCIT. The increased Tr1 cells by SCIT functionally suppressed allergic asthma probably via production of IL-10 in response to the specific antigen. Therefore, analyses of the induction mechanisms of Tr1 cells and search for compounds which induce Tr1 cells are thought to lead to development of more efficient SCIT.

Although many treatments for type 2 diabetes mellitus (T2DM) have been developed, the quality of life for people with T2DM still tends to be lower than in those without the disease. Thus, the development of new T2DM treatments and prevention methods is required. Genetic predisposition and environmental factors are understood to be involved in the onset and pathology of T2DM. Therefore, we have attempted to explore genes and foods with potential for use in the treatment and prevention of T2DM. LipoQuality, which describes the functional features of diverse lipid species, has recently been a focus of study in the pathology of metabolic diseases. Phospholipids, the major components of biological membranes, are known to change in composition during the development of obesity and diabetes. Therefore, for our research, we focused on genes that regulate the composition of phospholipids. We examined the effects of such genes on T2DM using an improved adenovirus vector that demonstrates safer, higher, and longer-term transgene expression than that of the conventional adenovirus vector. We also found that certain foods inhibit the progression of non-alcoholic fatty liver disease, which is related to T2DM. In this review, we introduce our research results, demonstrating how genes and food independently contribute to the mechanisms of T2DM pathology.

The importance of community-based care systems has increased due to the highly aging population and diversity of disease. To enhance the cooperation among healthcare professionals in community-based care systems, a two-day on-site training program for community pharmacists based on a multidisciplinary team approach was conducted at the Medical Science Hospital of Shiga University from April 2015 to March 2017. There were two professional courses in this training program: the palliative care course and nutrition support course. Both courses consisted of common pharmaceutical care training as follows: regional cooperation among healthcare professionals, pharmacist's clinical activities in the ward, pressure ulcer care, infection control, and aseptic technique for parenteral solutions. Each course was limited to 2 participants. A questionnaire was given to participants in the training program. Seventy-five pharmacists participated in the training and all of them answered the questionnaire. According to the questionnaire, 86% of participants felt that 2 days was an appropriate term for the training program. Positive answers regarding the content of each program and overall satisfaction were given by 100% and 99% of the participants, respectively. In the categorical classification of free comments regarding the expected change in pharmacy practice after the training, both "support for patients under nutritional treatment" and "cooperation with other medical staff" were answered by 24 participants. These results suggested that the 2-day on-site training for community pharmacists facilitated cooperation among healthcare professionals in the community.

We report a case of dural arteriovenous fistula at the left transverse sinus and sigmoid sinus(TS-dAVF), which was treated with transvenous embolization(TVE)by direct puncture of the superior sagittal sinus(SSS)under indocyanine green(ICG)fluoroscopic guidance. A 71-year-old woman presented with pulsatile tinnitus and progressive dementia. A left TS-dAVF with retrograde SSS and cortical venous reflux(Cognard type IIb)was demonstrated on cerebral angiography. The left internal jugular vein and distal portion of the right transverse sinus were occluded. We considered that TVE via the femoral vein would be difficult for complete cure. We performed trepanation of the frontal portion of the SSS. The SSS was directly punctured with an 18-G needle under ICG fluoroscopic guidance. We inserted a 4-Fr sheath into the SSS. A microcatheter was navigated into the affected sinus. Coils were placed through the microcatheter. The dAVF was completely diminished. No complications occurred. The patient's pulsatile tinnitus disappeared and dementia improved. Transvenous approach with direct puncture of the SSS under ICG fluoroscopic guidance was a useful approach for the treatment of dAVF when other approaches were difficult.

A 50-year-old woman presented with a subarachnoid hemorrhage caused by a ruptured vertebral artery dissecting aneurysm(VADA)involving the anterior spinal artery(ASA). The ASA branched at the proximal component of the dissecting aneurysm. The rupture point was presumed to be the distal region of the dissecting aneurysm. We performed coil embolization of the distal part only in order to prevent rebleeding and preserve the ASA. The patient showed no neurological deficits. Six months after the procedure, an angiogram demonstrated occlusion of a distal portion of the right vertebral artery. However, the ASA was still patent. No rebleeding occurred, and the patient has remained neurologically symptom-free for 3 years from the treatment. ASA-involved VADAs are extremely rare. Treatment strategy is difficult because there are no options for bypass surgery and occlusion of the ASA may lead to quadriplegia unless there is collateral flow to the ASA. Although the outcome of the patient was good with partial coil embolization in this case, the treatment strategy should be carefully considered for ASA-involved VADAs.

Objective: The objective of this study was to analyze the diagnosis and postoperative complications of benign parotid tumors for a series of 633 patients who underwent the same diagnostic methods and operation procedure in a single institute., Materials & Methods: A series of 633 patients who underwent parotidectomy for benign parotid tumors over a 16-year period was reviewed., Results: There were 345 female and 288 male patients. The site of the tumors was divided among three groups, superficial, deep, and lower pole tumors. The numbers of each type of above tumors were 342, 122, and 169 cases, respectively. The most common pathology of the parotid tumor was a pleomorphic adenoma (372 cases) followed by a Warthin tumor (166 cases). Pleomorphic adenomas and Warthin tumors accounted for 85% of all benign tumors. The accuracy rate of fine needle aspiration cytology (FNAC) for all benign tumors was 71%, 84% for pleomorphic adenomas and 72% for Warthin tumors. Transient facial nerve dysfunction was observed in 130 patients (21%) in 612 cases of primary benign parotid tumors, and only one patient developed a permanent weakness. The incidence of transient facial nerve dysfunction was 18% in superficial tumors, 39% in deep tumors, and 15% in lower pole tumors. Significant risk factors for development of a transient facial palsy were the site of the tumors, the size of the tumors, operation time, and bleeding volume. Among these risk factors, for the site of the tumors, the deep lobe was the most important factor associated with transient facial nerve dysfunction. Transient facial nerve dysfunction recovered within 6 months in 90% of all cases., Conclusions: The accuracy rate of FNAC for benign parotid tumors was 72%. The incidence of transient facial nerve dysfunction in deep tumors was significantly higher compared to that in superficial and lower pole tumors. According to the rate of facial palsy, operation time, and bleeding volume, benign parotid tumor should be divided among three groups, namely superficial, deep, and lower pole tumors.

After the year 2000, the treatment of cancer remarkably changed, including the development of outpatient cancer chemotherapy. Meanwhile, we have encountered many clinical problems related to cancer patient pharmacy services. To resolve these problems, I have tried to establish the individualized and optimal cancer pharmacotherapy utilizing the findings of basic research. In this review, three topics of my research will be introduced. 1) In 2005, information regarding the genetic polymorphism of UGT1A1*28 was described in the package insert of the drug irinotecan in the United States. At that time, however, there was little similar information for Japanese patients. Through clinical research, we demonstrated that UGT1A1*6 was a significant factor for neutropenia, as induced by irinotecan. 2) Tyrosine kinase inhibitors are mainly used at a fixed dose, but wide interpatient variability has been observed relative to their pharmacokinetics and/or pharmacodynamics. To overcome these variations, clinical and basic pharmacological research on erlotinib, sorafenib and sunitinib was carried out. Especially, in sunitinib therapy, we demonstrated that the breast cancer resistant protein in the intestine functions as a limiting factor for oral absorption, and that therapeutic drug monitoring could be helpful for avoiding severe toxicities, resulting in prolonged progression-free survival. 3) We quantitatively assessed side effect management by pharmacist intervention for outpatient chemotherapy. We calculated the improvement ratio between before and after pharmacist intervention, and found that 135 suggestions (50.8%) led to significant improvements, indicating that pharmacist intervention could be useful for attenuating the side effects of cancer chemotherapies.

A total of 109 patients with glottic squamous cell carcinoma were retrospectively evaluated at Hyogo College of Medicine Hospital between 2003 and 2010; 106 patients were male and 3 patients were female, with a median age of 69 years (range, 51-90 years). According to the 7th edition of the Union for International Cancer Control TNM classification, the clinical TN stages were T1aN0 in 47 cases, T1aN1 in 1 case, T1aN2a in 1 case, T1bN0 in 19 cases, T3N0 in 11 cases, T4aN in 5 cases, and T4aN2b in 1 case. No distant metastasis was observed in any cases at initial treatment. Treatments were radiotherapy alone in 75 cases, concurrent chemo-radiotherapy in 20 cases, supra-cricoid laryngectomy in 1 case, and total laryngectomy in 13 cases. Salvage surgery was performed for 14 patients who had undergone radiotherapy or concurrent chemo-radiotherapy. Salvage surgeries included frontolateral partial laryngectomy in 8 cases, supra-cricoid laryngectomy in 2 cases, and total laryngectomy in 4 cases. The 5-year overall survival rate was 77.6%, and the 5-year disease-specific survival rate was 92.5%. The 5-year laryngeal preservation rate was 82.9%. With regard to T-stages, the laryngeal preservation rates were 100% for T1a, 89.5% for T1b, 91.5% for T2, 18.2% for T3, and 16.7% for T4a.

Malignant tumors during pregnancy are rarely seen by otolaryngologists, and they cause various problems which require special treatment with careful consideration of both the mother and fetus. Cases of tongue carcinoma resection and reconstruction with a microsurgical free flap during pregnancy have not previously been reported in Japan. We report herein on a case, in which the mother and her child made satisfactory progress after surgery. A-33-year-old female at 25 weeks and 4 days of pregnancy was referred to our department for the treatment of a tumor on the right edge of her tongue. Examinations including biopsy revealed SCC (T2N0M0). We performed an operation to remove the tongue carcinoma with the pull-through method and reconstruct the tongue with an ALT flap at just 28 weeks of pregnancy. The postoperative recovery was favorable, and she gave natural birth to a girl safely at 38 weeks and 6 days of pregnancy. She is currently free of disease and her child is growing normally, at 2 years and 10 months after surgery.

Posterior cerebral artery (PCA) aneurysms are rare, especially those at the P4 segment. We report such a case involving a 77-year-old man who suffered from a sudden-onset headache. Computed tomography showed intracerebral hemorrhage in the left occipital lobe, intraventricular hemorrhage, and subarachnoid hemorrhage at the left occipital sulcus. Magnetic resonance angiography failed to reveal any aneurysms or abnormal vessels. Because the patient had renal dysfunction, we refrained from conventional angiography. Five days after the initial onset, rebleeding occurred, and conventional angiography revealed a small(2-mm)PCA aneurysm in the left P4 segment. We performed endovascular treatment and occluded the parent artery with a liquid embolic material, n-butyl-2-cyanoacrylate. The etiology of the aneurysm was not determined. The patient did not suffer from any apparent visual field deficits and was transferred to a rehabilitation hospital. Reviewing previous reports of distal PCA aneurysms indicated that PCA aneurysms in the P4 segment have two characteristics that distinguish them from other PCA aneurysms:P4 segment aneurysms are relatively small and the resulting hematoma distribution tends to be manifest as a combination of intracerebral hemorrhage, intraventricular hemorrhage, and subarachnoid hemorrhage at the occipital sulcus. With respect to these characteristics, our case was a typical P4 segment aneurysm. In conclusion, although P4 segment aneurysms are rare, if the characteristic hematoma distribution is observed, conventional angiography should be performed to confirm a possible P4 segment aneurysm. Parent artery occlusion with a liquid embolic material may be a treatment option for selected cases.

We enrolled 62 elderly patients( ≥70 years of age) with colorectal cancer who had undergone surgery and postoperative adjuvant chemotherapy at our department and analyzed the overall surviva(l OS) and disease-free surviva(l DFS) to identify the patients who responded to treatment. Postoperative adjuvant chemotherapy was performed with oral anticancer agents, including doxifluridine( 5'-DFUR), uracil/tegafur( UFT), and UFT/Leucovorin( LV); all patients also received polysaccharide K( PSK), an immunomodulator, in combination with chemotherapy. The 3-year OS and DFS rates for all patients were 83.4% and 78.6%, respectively, with no significant differences in these rates based on the chemotherapeutic agents used. The patients were assigned to low and high groups on the basis of the median cut-off values of each clinical laboratory parameter and the data obtained were subjected to univariate analysis. The results of the univariate analysis suggested that carcinoembryonic antigen (CEA) and cancer antigen 125 (CA125) levels were significant prognostic factors. Further multivariate analysis using Cox regression analysis identified the preoperative CEA level alone as an independent factor. When stratification analysis was performed using a preoperative CEA level of 4.0 ng/mL as the cut-off value, the results indicated that the outcome of patients with a high preoperative CEA level may be 8-fold worse than that of patients with a low preoperative CEA level. For these patients, the use of chemotherapeutic drugs that elicit a more potent antitumor effect should be considered.

Our modification of Starnes' procedure reduces right ventricular volume using only "suture plication" to improve surgical outcomes. However, shunt size in the procedure varies widely between patients. As this may be related to small lung volume, we estimated lung volume in each patient using computed tomography (CT).Since 2007, we have performed Starnes' procedure in 4 patients. Preoperative cardiothoracic ratio was 89±4.5%. Age and body weight at operation were 4.3±2.6 days and 2.6±0.2 kg, respectively. Anatomic slices 3 mm thick were acquired in transverse planes by CT. Total lung volume was calculated by accumulating those slices. Total lung volume and lung volume/body weight were 97.2±34.1 ml, 36.8±11.5 ml/kg, respectively. In one patient, a 3 mm prosthetic graft was needed to place a clip to regulate blood flow. Another patient required an additional shunt. The patient with the smallest lung volume required treatment with an extracorporeal lung-assistance device. Chest X-rays of neonates with severe Ebstein's anomaly usually show a "wall-to-wall" heart. However, lung volume varies widely between patients. Estimation of lung volume using CT is useful. In patients with smaller lung volume, a larger shunt than usual may be required to obtain the necessary pulmonary blood flow.

Accidental hypothermia is the state in which body temperature falls due for exposure to a chilly environment. In accidental hypothermia, the mortality rate is higher the lower the body temperature. We report a case of a consciousness disorder and severe hypothermia, with a body temperature below 28 degrees C, in which it later became clear that a cervical spinal cord injury had been caused by a small external force. A 70-year-old woman was transported to our hospital in an ambulance for consciousness disturbance and severe hypothermia. At the time of arrival, her rectal temperature was 26.2 degrees C. We promptly performed rewarming. Her consciousness level became clear, but paralysis and diminished sensation were observed below the C5 domain. We suspected cervical spinal cord injury and performed cervical magnetic resonance imaging. She was diagnosed as having C5 cervical spinal cord injury. When there is a consciousness disorder due to accidental hypothermia, it might not be possible to evaluate the neurological value of the cervical spinal cord injury correctly. The presence of cervical spinal cord injury should be considered when patients have a decreased consciousness level due to hypothermia.

Background: Pulmonary arterial hypertension (PAH) is associated with significant perioperative risk due to the severity of cardiac dysfunction related to the RV Tei index greater than 0.83. We evaluated the car- diovascular function during anesthesia to elucidate the characteristics of severity of PAH., Methods: Nine patients undergoing central venous catheterization under general anesthesia (seven patients) and local anesthesia with sedation (two patients) were studied. RV Tei index of five patients were greater than 0.83 (severe) and in four patients RV Tei index was below 0.83 (moderate). Bioimpedance method was used to determine stroke volume (SV) and cardiac output (CO) non-invasively throughout anesthesia. The correlation between the changes in SV and CO was evaluated by using least squares method., Results: Demographic data showed mean age of 16.6 years, height of 146.9 cm and weight of 39.7 kg. Correlation coefficient of SV and CO in the patients with severe cardiac dysfunction was 0.0-0.21, while in those with moderate cardiac dysfunction it was 0.49-0.93., Conclusions: In patients with severe PAH, it was demonstrated that CO is maintained by the change in heart rate (HR) but not by SV It is suggested that the control of HR in patients with PAH is of clinical importance in order to maintain CO, if RV index is greater than 0.83.

From January 2000 to December 2008, we conducted voice rehabilitation using the Provox2 voice prosthesis total-laryngectomy subjects. Of these, 36 attained restoration of 90.0%. Mean maximum phonation time (MPT) was 14.5s, ranging from MPT was not influenced by age, radiotherapy use, primary tumor site, or reconstructive surgery use. Voice prosthesis replacement averaged 25 weeks (5.8 months), ranging from 9 to 74 weeks. Complications occurred in 16 caces (40.0%), mainly granulation tissue formation and prosthesis-site infection, also aspiration pneumonia, prosthesis-site salivary leakage, inability to replace the prosthesis, tracheomalacia, bodies in the trachea. Management rather than medical problems included cost, frequent hospital visits, and lack of motivation to use a prosthesis. The Provox2 voice prosthesis speech provides a higher rate of speech restoration, longer phonatory better intelligibility. Management problems, however, require that we work to understand subjects' living environments and family situations better for evaluating Provox2 voice prosthesis indication more effectively.

We report a case of alphafetoprotein (AFP)-producing gastric cancer that accompanied early gastric cancer and was treated effectively by chemotherapy. The patient was a 73-year-old male. A type 1 tumor was observed in the upper gastric body and a 0-IIa tumor was noted on the anterior wall of the lower gastric body. Abdominal CT showed multiple metastatic lesions in the liver. A subtotal gastrectomy was performed, and the pathological examination revealed that the type 1 tumor was positive for AFP and the 0-IIa tumor was negative for AFP. After 5 courses of postoperative administration of S-1, hepatic metastatic lesions disappeared on imaging. The serum AFP level, which had increased to the maximum of 49,660 ng/ml, was normalized. After 60 months, there has been no sign of recurrence. We encountered a case of AFP-producing gastric cancer that accompanied early gastric cancer and was treated effectively by S-1. Various therapies for AFP-producing gastric cancer have been reported; however, a standardized regimen has not been established. Since the concurrence of AFP-producing gastric cancer and tubular adenocarcinoma is rare, and hepatic metastatic lesions disappeared, the case under study is considered to be of interest. Therefore, we report this case with a review of the literature.

Background: Clinical usefulness of PA catheter is controversial. We compared a new semi-invasive device (FloTrac/Vigileo) using arterial pressure waveform analysis for CO measurement in patients undergoing renal transplantation with bolus thermodilution method. Simultaneously CCO was measured, and we compared CCO with that obtained by bolus thermodilution method., Methods: Forty seven patients undergoing renal transplantation were enrolled. A PAC was inserted and radial arterial access was used for semi-invasive determination of CO (APCO) with the Vigileo. CO was measured simultaneously by bolus thermodilution and the Vigileo technique, and after starting operation, volume loading, before surgery, and other points were measured over 1 hour during measurements. And CCO was measured simultaneously at all points., Statistical Analysis: Statistical analysis was performed using the method described by Bland and Altman. Bias was defined as the mean difference between the volumes obtained by pulmonary artery thermodilution and those by arterial pressure waveform analysis. Precision was expressed by the upper and lower limits of agreement., Results: Means of age, height and weight were 45 years, 163.8 cm and 59.2 kg, respectively. Regression analysis of CO; APCO and ICO showed y = 0.8x + 2.2, R2 = 0.57. CCO and ICO; y = 0.8x + 1.1, R2 = 0.74. Average of APCO and ICO; bias = -0.65. SD = 1.54 average of CCO and ICO; bias = 0.38, SD = 1.23., Conclusions: In renal transplantation, CO measured by a new semi-invasive arterial pressure waveform analysis device showed good agreement with the volume obtained by intermittent pulmonary artery thermodilution method.

Frontal Assessment Battery (FAB) is short neuropsychological battery for the bed side screening of frontal lobe function. Several studies have indicated that frontal lobe dysfunction is the main neuropsychological feature in Amyotrophic lateral sclerosis (ALS). We examined frontal lobe function in patients with ALS and in age-matched normal subjects by using the FAB. We examined 24 patients with sporadic ALS aged 66.0 +/- 10.1 years, with a mean disease duration of 2.0 +/- 0.7 years, a Mini-Mental State Examination score of > or = 24, a normal self-rating depression score, no dyspnea, and no or only slight disturbances in speech, cutting food, and handling utensils on the ALS Functional Rating Scale. Total FAB score, similarity score, and lexical fluency score were significantly lower in ALS patients. Total FAB score did not correlate with age, disease duration, ALS Functional Rating Scale, spirometry, or blood gas analyses. These results suggest frontal lobe dysfunction in ALS patients.

Background: Performing epidural anesthesia is accompanied by pain. The aim of this study is to examine whether intravenous administration of a sedative, an opioid, or an anesthetic eliminates pain score during the epidural procedure., Methods: Two-hundred and fifty-nine patients undergoing epidural anesthesia were randomly allocated into six groups. Prior to the epidural anesthesia, midazolam, fentanyl, ketamine, midazolam plus fentanyl or midazolam plus ketamine was given intravenously to the patients in each group. After the procedure, the effects of these drugs on pain relief in the patients were assessed by visual analogue scale(VAS)., Results: VAS was significantly decreased in all drug-treated groups to a similar extent, as compared with drug-free group. There was no significant difference between the drug-treated groups. Serious side effects including persistent respiratory suppression were not observed in this study., Conclusions: The findings obtained from this study suggest that the analgesic action of the drug is not essential to the pain relief and the anxiolytic action is important for the epidural procedure.

Background: Clinical significance of PA catheter is controversial. FloTrac sensor bases its calculations on arterial waveform characteristics. We conducted a pilot assessment of the FloTrac sensor by three versions comparing with pulmonary artery catheter (PCA) methodology., Methods: Five patients undergoing cardiac surgery and four patients undergoing renal transplantation were enrolled. A PAC was inserted and radial arterial access was used for semi-invasive determination of CO (APCO) with the Vigileo. CO was measured simultaneously by bolus thermodilution and the Vigileo technique, and CCO was measured simultaneously., Results: The correlation with output obtained by FloTrac and obtained by PCA is better with the newer version. Bland Altman analyses demonstrated better agreement between FloTrac and PCA methodology of the newer version., Conclusions: CO measured by a new semi-invasive arterial pressure waveform analysis device showed better agreement with pulmonary artery thermodilution measurement of the newer version.

Allergic responses are strongly associated with Th2-type immune responses, and modulation of the skewed Th2 response toward a more balanced response is the major goal of allergen immunotherapy (IT) in allergic disorders. To achieve this goal, several approaches have been tested. The author found that human gamma-allergen fusion protein achieve an inhibitory effect in an allergen-specific fashion while preserving the immunogenicity of the allergen component. Therefore, the authors constructed and developed a human-cat chimeric fusion protein composed of the human Fcgammal and the cat allergen Fel d1 (Felis domesticus) for cat allergen-specific IT. This article summarizes the therapeutic features and potential of this novel fusion protein for allergic IT.

The Fontan procedure is performed for patients with a corrected transposition of great arteries, and pregnancies following this surgery are likely to increase in number. We present a parturient with the Fontan physiology. In this case, we used thoracic bio-impedance cardiac output monitoring system "TaskForce Monitor". It was shown that the cardiovascular management by using TaskForce Monitor was useful because of the non-invasive beat-to-beat cardiac output monitoring.

A 61-year-old man presented with the complaint of headache. Investigations revealed a fusiform middle cerebral artery aneurysm at the M2 part. The formation of the aneurysm rapidly developed to a partially thrombosed aneurysm in the course of four months. As regards the treatment of the aneurysm, at first we tried surgery with a superficial temporal artery middle cerebral artery bypass (STA-MCA bypass) and trapping of the aneurysm. However, during the procedure, it was difficult to control bleeding from the temporal muscle, bone flap, and subdural space. Because of this, we finished the STA-MCA bypass without trapping of the aneurysm and then, four days later, we confirmed bypass patency and treated the aneurysm using endovascular coil embolization. Based on both surgical and interventional investigations in this case and a review of the reported literature, the authors propose that there are two mechanisms causing the middle cerebral artery fusiform aneurysm to develop thrombosed formation rapidly: (i) Peripheral middle cerebral artery branches demand less blood flow than other major trunk arteries. (ii) Bypass flow maintains perfusion to the distal branches. On the other hand, this flow alteration caused by surgical vascular bypass may promote the development of the aneurysm to thrombosed formation. The treatment of a fusiform middle cerebral artery aneurysm at the M2 part is also discussed.

There has been little information about anesthesia for a patient with a history of multiple drug allergies. We gave anesthesia for a 32-year-old woman with polyarteritis nodosa and history of multiple drug allergies. She was scheduled to undergo bilateral tonsilectomy. We could not perform the preoperative screening of the drugs using a dermal test because of a high risk of anaphylactic shock. Anesthesia was induced with sevoflurane and nitrous oxide and maintained with sevoflurane, nitrous oxide, and fentanyl. The intra- and postoperative course was uneventful. It is important to inquire history of allergies adequately for preoperative recognition of allergens. General anesthesia with sevoflurane would be useful for a patient with history of multiple drug allergies.